Healthcare Provider Details

I. General information

NPI: 1205729548
Provider Name (Legal Business Name): NICOLE MARIE DE LA VEGA APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9655 N 5750 W
HIGHLAND UT
84003-9150
US

IV. Provider business mailing address

9655 N 5750 W
HIGHLAND UT
84003-9150
US

V. Phone/Fax

Practice location:
  • Phone: 801-473-4341
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number37020-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: