Healthcare Provider Details

I. General information

NPI: 1114688819
Provider Name (Legal Business Name): NICOLETTE MOORE APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 E FORT UNION BLVD STE 101
SALT LAKE CITY UT
84121-2881
US

IV. Provider business mailing address

2387 N 3130 W
LEHI UT
84043-7308
US

V. Phone/Fax

Practice location:
  • Phone: 801-997-8881
  • Fax:
Mailing address:
  • Phone: 801-854-3854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7487553-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: