MEDICARE: NICOLETTE MOORE APRN, FNP-BC

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	363LF0000X	Family Nurse Practitioner	7487553-4405	UT

General Provider Information

NPI Number	:	1114688819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLETTE MOORE APRN, FNP-BC

Provider Business Mailing Address
First Line	:	2387 N 3130 W
Second Line	:
City	:	LEHI
State	:	UT
Zip	:	84043-7308
Country	:	US
Telephone Number	:	801-854-3854
Fax Number	:

Provider Business Practice Location Address
First Line	:	1770 E FORT UNION BLVD STE 101
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-2881
Country	:	US
Telephone Number	:	801-997-8881
Fax Number	:

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

Provider Enumeration Date	:	01/04/2022
Last Update Date	:	01/04/2022

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