MEDICARE: NICOLE NOKLEBY DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	9431602-2401	UT

General Provider Information

NPI Number	:	1528424447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE NOKLEBY DPT

Provider Business Mailing Address
First Line	:	4209 S JUPITER DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-3374
Country	:	US
Telephone Number	:	801-921-3725
Fax Number	:

Provider Business Practice Location Address
First Line	:	4209 S JUPITER DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-3374
Country	:	US
Telephone Number	:	801-921-3725
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2016
Last Update Date	:	01/07/2016

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