Healthcare Provider Details

I. General information

NPI: 1497040216
Provider Name (Legal Business Name): MS. CHANTEL M FICKLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N 200 W SUIT 300
PROVO UT
84601-1677
US

IV. Provider business mailing address

750 N 200 W SUIT 300
PROVO UT
84601-1677
US

V. Phone/Fax

Practice location:
  • Phone: 801-373-4760
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: