Healthcare Provider Details

I. General information

NPI: 1356757793
Provider Name (Legal Business Name): HEATHER NICHOLSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 3RD AVE
JASPER IN
47546-3503
US

IV. Provider business mailing address

504 3RD AVE
JASPER IN
47546-3503
US

V. Phone/Fax

Practice location:
  • Phone: 812-964-5750
  • Fax: 812-964-5750
Mailing address:
  • Phone: 812-964-5750
  • Fax: 812-964-5750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28166000C
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71004996A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: