Healthcare Provider Details

I. General information

NPI: 1063727204
Provider Name (Legal Business Name): NICOLE L STEVENSON MSN-NPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE L BRENNER

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 06/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 E ILLINOIS ST
PETERSBURG IN
47567-8068
US

IV. Provider business mailing address

PO BOX 1028
JASPER IN
47547-1028
US

V. Phone/Fax

Practice location:
  • Phone: 812-354-3485
  • Fax: 812-354-3459
Mailing address:
  • Phone: 812-996-5255
  • Fax: 812-996-8497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71003367A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71003367A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: