Provider Demographics
NPI:1144303983
Name:NICKLE, CHELLE (OD)
Entity type:Individual
Prefix:MRS
First Name:CHELLE
Middle Name:
Last Name:NICKLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 N 1000 W
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-2485
Mailing Address - Country:US
Mailing Address - Phone:801-444-7124
Mailing Address - Fax:
Practice Address - Street 1:57 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-3517
Practice Address - Country:US
Practice Address - Phone:801-447-4393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT375826-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT375826-9934OtherUTAH OPTOMETRIST LICENSE
UT375826-8908OtherUTAH OD CONTROLLED SUBSTA
UT375826-9934OtherUTAH OPTOMETRIST LICENSE
UT000055643Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
UT375826-8908OtherUTAH OD CONTROLLED SUBSTA