1518492743 NPI number — NICOLE NIELSEN DAVIS MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518492743 NPI number — NICOLE NIELSEN DAVIS MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

DAVIS

Provider First Name:

NICOLE

Provider Middle Name:

NIELSEN

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1518492743

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/13/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 705

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

SALT LAKE CITY

Provider Business Mailing Address State Name:

UT

Provider Business Mailing Address Postal Code:

84110-0705

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

801-448-6454

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

177 E 900 S STE 203

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

SALT LAKE CITY

Provider Business Practice Location Address State Name:

UT

Provider Business Practice Location Address Postal Code:

84111-4252

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

801-448-6454

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

04/25/2017

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207Q00000X , with the licence number:  4859812-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: CDR.0001262 . This is a "COLORADO MEDICAL LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
• Identifier: 13843 . This is a "SOUTH DAKOTA MEDICAL LICENSE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
• Identifier: 328280 . This is a "LOUISIANA MEDICAL LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
• Identifier: MD.43646 . This is a "ALABAMA MEDICAL LICENSE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
• Identifier: MD207221 . This is a "OREGON MEDICAL LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
• Identifier: THMD00023 . This is a "ARIZONA MEDICAL LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
• Identifier: 19019 . This is a "NORTH DAKOTA MEDICAL LICENSE" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
• Identifier: 4859812-1205 . This is a "UTAH MEDICAL LICENSE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
• Identifier: A169764 . This is a "CALIFORNIA MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
• Identifier: MD61214576 . This is a "WASHINGTON MEDICAL LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
• Identifier: ME1674 . This is a "FLORIDA MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: U0473 . This is a "TEXAS MEDICAL LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".