Healthcare Provider Details

I. General information

NPI: 1356290910
Provider Name (Legal Business Name): KIERRA DOUGLASS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2723 S 7TH ST STE A
TERRE HAUTE IN
47802-3558
US

IV. Provider business mailing address

1942 COBBLESTONE WAY S
TERRE HAUTE IN
47802-5411
US

V. Phone/Fax

Practice location:
  • Phone: 812-232-8164
  • Fax:
Mailing address:
  • Phone: 812-232-8164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71017623A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: