MEDICARE: NICOLE MARIE LEDESMA-GOINS

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	363L00000X	Nurse Practitioner	1215387	TX
2	363LF0000X	Family Nurse Practitioner	74939	NM

General Provider Information

NPI Number	:	1700567864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MARIE LEDESMA-GOINS

Provider Business Mailing Address
First Line	:	PO BOX 1200
Second Line	:
City	:	PLEASANT GROVE
State	:	UT
Zip	:	84062-1200
Country	:	US
Telephone Number	:	800-640-3451
Fax Number	:

Provider Business Practice Location Address
First Line	:	2011 N COLLINS BLVD STE 607
Second Line	:
City	:	RICHARDSON
State	:	TX
Zip	:	75080-2636
Country	:	US
Telephone Number	:	800-640-3451
Fax Number	:

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

Provider Enumeration Date	:	07/31/2023
Last Update Date	:	04/07/2026

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Directions to “ NICOLE MARIE LEDESMA-GOINS ” Practice Location

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