MEDICARE: JEREMY KEITH NIVENS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	28198910A	IN
2	363L00000X	Nurse Practitioner	71005349A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780896431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY KEITH NIVENS NP

Provider Business Mailing Address
First Line	:	111 NEW HAMPSHIRE AVE STE 2
Second Line	:
City	:	PORTSMOUTH
State	:	NH
Zip	:	03801-2864
Country	:	US
Telephone Number	:	330-947-6021
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 SOUTHFIELD DR STE 1240
Second Line	:
City	:	PLAINFIELD
State	:	IN
Zip	:	46168-4499
Country	:	US
Telephone Number	:	317-838-9911
Fax Number	:	317-837-6080

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	07/17/2025

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