Healthcare Provider Details

I. General information

NPI: 1972294650
Provider Name (Legal Business Name): NICHOLE L ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 N 400 E
LOGAN UT
84341-2321
US

IV. Provider business mailing address

6850 S 3600 W
WELLSVILLE UT
84339-9359
US

V. Phone/Fax

Practice location:
  • Phone: 801-871-5118
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14222563-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: