Provider Demographics
NPI:1992253199
Name:THORSEN, NICOLE LEE (CNM)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:THORSEN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 E VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-1059
Mailing Address - Country:US
Mailing Address - Phone:435-565-0659
Mailing Address - Fax:
Practice Address - Street 1:900 ROUND VALLEY DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7552
Practice Address - Country:US
Practice Address - Phone:435-658-7264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7484374-4402367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife