MEDICARE: SANDRA LOUISE MCNICOLL APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	2151388900	UT

General Provider Information

NPI Number	:	1073533188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA LOUISE MCNICOLL APRN

Provider Business Mailing Address
First Line	:	PO BOX 27128
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84127-0128
Country	:	US
Telephone Number	:	801-314-4544
Fax Number	:

Provider Business Practice Location Address
First Line	:	5801 FASHION BLVD STE 175
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84107-8115
Country	:	US
Telephone Number	:	801-314-4544
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	10/16/2007

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