Provider Demographics
NPI:1073533188
Name:MCNICOLL, SANDRA LOUISE (APRN)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LOUISE
Last Name:MCNICOLL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-314-4544
Mailing Address - Fax:
Practice Address - Street 1:5801 FASHION BLVD STE 175
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-8115
Practice Address - Country:US
Practice Address - Phone:801-314-4544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2151388900363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT006902310Medicare PIN
UT005542346Medicare PIN
UT005531002Medicare PIN