Healthcare Provider Details

I. General information

NPI: 1699484238
Provider Name (Legal Business Name): NICOLE GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11631 S 700 E
DRAPER UT
84020-8288
US

IV. Provider business mailing address

11312 S BERG HOLLOW LN
SOUTH JORDAN UT
84095-4023
US

V. Phone/Fax

Practice location:
  • Phone: 801-712-8907
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number14226749-4104
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: