Healthcare Provider Details

I. General information

NPI: 1851122352
Provider Name (Legal Business Name): NICHOLE MARTIN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13894 S BANGERTER PKWY STE 200
DRAPER UT
84020-5320
US

IV. Provider business mailing address

2175 REDHEAD DR
SPARKS NV
89441-7873
US

V. Phone/Fax

Practice location:
  • Phone: 385-454-5027
  • Fax:
Mailing address:
  • Phone: 775-233-4015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number880269
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: