MEDICARE: NICOLE MARIN KERTAMUS

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	1041C0700X	Clinical Social Worker	13633645-3502	UT

General Provider Information

NPI Number	:	1376079673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MARIN KERTAMUS

Provider Business Mailing Address
First Line	:	76 E INLET SPRING DR
Second Line	:
City	:	SARATOGA SPRINGS
State	:	UT
Zip	:	84045-5567
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3725 W 4100 S STE 150
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-5419
Country	:	US
Telephone Number	:	801-578-2351
Fax Number	:

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

Provider Enumeration Date	:	05/04/2017
Last Update Date	:	11/06/2023

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