Provider Demographics
NPI:1497341994
Name:HARRIS, NICOLE MARIE (MSN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 E HAMILTON RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-7527
Mailing Address - Country:US
Mailing Address - Phone:309-827-4090
Mailing Address - Fax:
Practice Address - Street 1:207 E HAMILTON RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7527
Practice Address - Country:US
Practice Address - Phone:309-827-4090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.021964363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health