Provider Demographics
NPI:1063727204
Name:STEVENSON, NICOLE L (MSN-NPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:MSN-NPC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:BRENNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1028
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47547-1028
Mailing Address - Country:US
Mailing Address - Phone:812-996-5255
Mailing Address - Fax:812-996-8497
Practice Address - Street 1:1003 E ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47567-8068
Practice Address - Country:US
Practice Address - Phone:812-354-3485
Practice Address - Fax:812-354-3459
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003367A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28164932AOtherINDIANA STATE LICENSE
IN200996500Medicaid
KY7100275180Medicaid