Healthcare Provider Details

I. General information

NPI: 1346156692
Provider Name (Legal Business Name): MARILYN NICHOLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CONNIE NICHOLES

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W BELLWOOD LN STE 1
SALT LAKE CITY UT
84123-4494
US

IV. Provider business mailing address

605 E 360 S
AMERICAN FORK UT
84003-2646
US

V. Phone/Fax

Practice location:
  • Phone: 702-857-8800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: