Healthcare Provider Details

I. General information

NPI: 1215717020
Provider Name (Legal Business Name): NICOLE KAY IPSON REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE KAY MARTINEZ REGISTERED NURSE

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 10/02/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL BLVD
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

312 DAWSON LN
TOOELE UT
84074-8975
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone: 385-272-6271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number8419562-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: