Healthcare Provider Details

I. General information

NPI: 1871429977
Provider Name (Legal Business Name): NICHOLE JOY VIRGIL OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 N 1000 W
LOGAN UT
84321-6846
US

IV. Provider business mailing address

1160 N 1000 W
LOGAN UT
84321-6846
US

V. Phone/Fax

Practice location:
  • Phone: 435-915-4229
  • Fax:
Mailing address:
  • Phone: 435-915-4229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14293155-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: