Provider Demographics
NPI:1164192951
Name:CLOVER, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CLOVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MICHELLE
Other - Last Name:CHRISTENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:2650 E BLACKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7302
Mailing Address - Country:US
Mailing Address - Phone:208-869-5209
Mailing Address - Fax:
Practice Address - Street 1:449 S FITNESS PL
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6828
Practice Address - Country:US
Practice Address - Phone:208-957-6301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SLP-3877235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty