Healthcare Provider Details

I. General information

NPI: 1942718473
Provider Name (Legal Business Name): KRISTI LEAVITT NICHOLS CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 11/22/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 W 2100 S
SALT LAKE CITY UT
84119-1407
US

IV. Provider business mailing address

5505 S FJORD CIR
TAYLORSVILLE UT
84129-2342
US

V. Phone/Fax

Practice location:
  • Phone: 801-213-9900
  • Fax:
Mailing address:
  • Phone: 801-647-2627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number7957869-4402
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number7957869-4402
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: