Healthcare Provider Details

I. General information

NPI: 1366642365
Provider Name (Legal Business Name): HEATHER RUTHANN NICHOLS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 S 9TH ST
VINCENNES IN
47591-2709
US

IV. Provider business mailing address

514 S 9TH ST
VINCENNES IN
47591-2709
US

V. Phone/Fax

Practice location:
  • Phone: 812-882-8510
  • Fax: 812-885-8511
Mailing address:
  • Phone: 812-882-8510
  • Fax: 812-885-8511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01068320A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: