MEDICARE: LINDA SMITH NILSON FNP-C

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	196314-4405	UT

General Provider Information

NPI Number	:	1760596225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINDA SMITH NILSON FNP-C

Provider Business Mailing Address
First Line	:	573 WEST 1890 NORTH
Second Line	:
City	:	WEST BOUNTIFUL
State	:	UT
Zip	:	84087-1156
Country	:	US
Telephone Number	:	801-298-5652
Fax Number	:

Provider Business Practice Location Address
First Line	:	415 MEDICAL DR
Second Line	:	#D - 101
City	:	BOUNTIFUL
State	:	UT
Zip	:	84010-4946
Country	:	US
Telephone Number	:	801-298-2332
Fax Number	:	801-298-5018

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

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	07/08/2007

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