Healthcare Provider Details

I. General information

NPI: 1972468098
Provider Name (Legal Business Name): NICOLLETTE WALES PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 PARK MEADOWS DR UNIT 732
LONE TREE CO
80124-5461
US

IV. Provider business mailing address

10200 PARK MEADOWS DR UNIT 732
LONE TREE CO
80124-5461
US

V. Phone/Fax

Practice location:
  • Phone: 801-419-7308
  • Fax:
Mailing address:
  • Phone: 801-419-7308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberSTUDENT
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: