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General NPI Number Information
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NPI Number | 1518492743
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Entity Type | Individual
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Provider Name | NICOLE NIELSEN DAVIS MD
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Gender | Female
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Dates
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Enumeration Date | 04/25/2017
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Last Update Date | 07/13/2023
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Provider Practice Location Address
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Address Line | 177 E 900 S STE 203
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City | SALT LAKE CITY
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State | UT
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Zip | 84111-4252
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Country | US
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Telephone | 801-448-6454
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 705
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City | SALT LAKE CITY
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State | UT
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Zip | 84110-0705
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Country | US
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Telephone | 801-448-6454
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4859812-1205
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License Number State | UT
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