Basic Information
| Provider Information | |||||||||
| NPI: | 1831245786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKLE | ||||||||
| FirstName: | TERESANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC, PMHNP-BC, DN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5831 S HARBISON AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462399658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055064700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4723 W. MAIN ST. | ||||||||
| Address2: | STE H | ||||||||
| City: | GUADALUPE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053435577 | ||||||||
| FaxNumber: | 8052490091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN501703 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 501703 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 501703 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 71012379A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | RN501703 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.