Provider Demographics
NPI:1114688819
Name:MOORE, NICOLETTE (APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2387 N 3130 W
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-7308
Mailing Address - Country:US
Mailing Address - Phone:801-854-3854
Mailing Address - Fax:
Practice Address - Street 1:1770 E FORT UNION BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-2881
Practice Address - Country:US
Practice Address - Phone:801-997-8881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7487553-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily