Provider Demographics
NPI:1518492743
Name:DAVIS, NICOLE NIELSEN (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:NIELSEN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 705
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-0705
Mailing Address - Country:US
Mailing Address - Phone:801-448-6454
Mailing Address - Fax:
Practice Address - Street 1:177 E 900 S STE 203
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-4252
Practice Address - Country:US
Practice Address - Phone:801-448-6454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4859812-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCDR.0001262OtherCOLORADO MEDICAL LICENSE
SD13843OtherSOUTH DAKOTA MEDICAL LICENSE
LA328280OtherLOUISIANA MEDICAL LICENSE
ALMD.43646OtherALABAMA MEDICAL LICENSE
ORMD207221OtherOREGON MEDICAL LICENSE
AZTHMD00023OtherARIZONA MEDICAL LICENSE
ND19019OtherNORTH DAKOTA MEDICAL LICENSE
UT4859812-1205OtherUTAH MEDICAL LICENSE
CAA169764OtherCALIFORNIA MEDICAL LICENSE
WAMD61214576OtherWASHINGTON MEDICAL LICENSE
FLME1674OtherFLORIDA MEDICAL LICENSE
TXU0473OtherTEXAS MEDICAL LICENSE