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General NPI Number Information
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NPI Number | 1376079673
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Entity Type | Individual
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Provider Name | NICOLE MARIN KERTAMUS
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Gender | Female
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Dates
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Enumeration Date | 05/04/2017
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Last Update Date | 11/06/2023
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Provider Practice Location Address
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Address Line | 3725 W 4100 S STE 150
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City | WEST VALLEY CITY
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State | UT
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Zip | 84120-5419
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Country | US
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Telephone | 801-578-2351
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Fax |
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Provider Business Mailing Address
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Address Line | 76 E INLET SPRING DR
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City | SARATOGA SPRINGS
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State | UT
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Zip | 84045-5567
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 13633645-3502
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License Number State | UT
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