Provider Demographics
NPI:1831245786
Name:NICKLE, TERESANN (FNP-BC, PMHNP-BC, DN)
Entity type:Individual
Prefix:DR
First Name:TERESANN
Middle Name:
Last Name:NICKLE
Suffix:
Gender:F
Credentials:FNP-BC, PMHNP-BC, DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5831 S HARBISON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-9658
Mailing Address - Country:US
Mailing Address - Phone:505-506-4700
Mailing Address - Fax:
Practice Address - Street 1:4723 W. MAIN ST.
Practice Address - Street 2:STE H
Practice Address - City:GUADALUPE
Practice Address - State:CA
Practice Address - Zip Code:93434
Practice Address - Country:US
Practice Address - Phone:805-343-5577
Practice Address - Fax:805-249-0091
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN501703363LF0000X, 363LP0808X
CA501703363LF0000X, 363LP0808X
IN71012379A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily