Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 84056654405 | UT |
NPI | 1003345141 |
---|---|
Provider Name | Nichole Chalise Nelson |
First Address | Salem, UT 84653-9304 |
Second Address | Pleasant Grove, UT 84062-3216 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2017 |
Last Update Date | 11/06/2017 |