Provider Demographics
NPI:1568949733
Name:WHITLOCK, NIKKI R (LMT)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:R
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:
Other - Last Name:RAE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:1223 E SIERRA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2417
Mailing Address - Country:US
Mailing Address - Phone:831-325-4288
Mailing Address - Fax:
Practice Address - Street 1:1155 E WILMINGTON AVE STE 250
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-7808
Practice Address - Country:US
Practice Address - Phone:831-325-4288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10698822-0151225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist