Provider Demographics
NPI:1023472735
Name:HISE, NICHOLLE M (NP)
Entity type:Individual
Prefix:
First Name:NICHOLLE
Middle Name:M
Last Name:HISE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NICHOLLE
Other - Middle Name:M
Other - Last Name:RODGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1060 S MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072-8327
Practice Address - Country:US
Practice Address - Phone:765-675-7009
Practice Address - Fax:765-675-3914
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2025-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006134A363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201354720Medicaid