Provider Demographics
NPI:1215493838
Name:SQUIRES, NIKOLE DECKER (LAT, ATC, CPT)
Entity type:Individual
Prefix:
First Name:NIKOLE
Middle Name:DECKER
Last Name:SQUIRES
Suffix:
Gender:F
Credentials:LAT, ATC, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 N 1260 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-2436
Mailing Address - Country:US
Mailing Address - Phone:480-318-3949
Mailing Address - Fax:
Practice Address - Street 1:6748 W 9500 N
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-3455
Practice Address - Country:US
Practice Address - Phone:480-318-3949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10877423-48102081S0010X, 2083S0010X, 2255A2300X
UTTBA405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10877423-4810OtherUT DIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING
2000031617OtherNATIONAL ATHLETIC TRAINERS' ASSOCIATION BOARD OF CERTIFICATION, INC.
TBAOtherNATIONAL ACADEMY OF SPORTS MEDICINE