Healthcare Provider Details

I. General information

NPI: 1114888724
Provider Name (Legal Business Name): HALEY NICOLE NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 S DAISY DR
FRUIT HEIGHTS UT
84037-3234
US

IV. Provider business mailing address

927 S DAISY DR
FRUIT HEIGHTS UT
84037-3234
US

V. Phone/Fax

Practice location:
  • Phone: 801-540-7140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: