Healthcare Provider Details

I. General information

NPI: 1780201293
Provider Name (Legal Business Name): HEATHER PATRICIA NICK MS GC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5171 S COTTONWOOD ST
MURRAY UT
84107-5704
US

IV. Provider business mailing address

2138 S PRESTON ST
SALT LAKE CITY UT
84106-4111
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3983
  • Fax: 801-507-3998
Mailing address:
  • Phone: 561-801-3984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number11794933-3602
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: