Healthcare Provider Details

I. General information

NPI: 1407770761
Provider Name (Legal Business Name): NICOLE LYNN PETERSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 N 650 W
OREM UT
84057-8407
US

IV. Provider business mailing address

1045 N 650 W
OREM UT
84057-8407
US

V. Phone/Fax

Practice location:
  • Phone: 801-404-4142
  • Fax:
Mailing address:
  • Phone: 801-404-4142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14301569-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: