Healthcare Provider Details

I. General information

NPI: 1124350137
Provider Name (Legal Business Name): NICHOLE CUDDEBACK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9660 S 1300 E
SANDY UT
84094-3762
US

IV. Provider business mailing address

11820 S STATE ST STE 150
DRAPER UT
84020-7140
US

V. Phone/Fax

Practice location:
  • Phone: 801-727-2056
  • Fax: 770-701-6675
Mailing address:
  • Phone: 801-568-0200
  • Fax: 801-563-0200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024168646
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3094717-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: