Provider Demographics
NPI:1235488008
Name:MEDINA, NICOLE I (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:I
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SHEWEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:5965 S 900 E STE 100
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-1850
Mailing Address - Country:US
Mailing Address - Phone:801-872-5516
Mailing Address - Fax:
Practice Address - Street 1:5965 S 900 E
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84121-1757
Practice Address - Country:US
Practice Address - Phone:801-872-5516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10158726-2501103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10158726-2501OtherPROFESSIONAL LICENSE
UT1235488008Medicaid