Healthcare Provider Details

I. General information

NPI: 1396006003
Provider Name (Legal Business Name): MELISSA SUE NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 W 300 N
HYDE PARK UT
84318-4044
US

IV. Provider business mailing address

338 W 300 N
HYDE PARK UT
84318-4044
US

V. Phone/Fax

Practice location:
  • Phone: 435-774-4113
  • Fax: 435-535-3197
Mailing address:
  • Phone: 435-774-4113
  • Fax: 435-535-3197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8957395-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: