Provider Demographics
NPI:1215717020
Name:IPSON, NICOLE KAY (REGISTERED NURSE)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:KAY
Last Name:IPSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:KAY
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:312 DAWSON LN
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-8975
Mailing Address - Country:US
Mailing Address - Phone:385-272-6271
Mailing Address - Fax:
Practice Address - Street 1:500 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8419562-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse