Provider Demographics
NPI:1114044187
Name:NICHOLSON, DIANE E (PT, NCS)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:E
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:PT, NCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2026 ASHLEY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-7259
Mailing Address - Country:US
Mailing Address - Phone:801-520-3077
Mailing Address - Fax:
Practice Address - Street 1:520 WAKARA WAY STE 320
Practice Address - Street 2:UNIVERSITY OF UTAH
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1213
Practice Address - Country:US
Practice Address - Phone:801-581-3593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT121711-24012251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology