Provider Demographics
NPI:1619546819
Name:NICOLAS, CLARE (AUD)
Entity Type:Individual
Prefix:
First Name:CLARE
Middle Name:
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4519 S ARCADIA GREEN WAY
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4190
Mailing Address - Country:US
Mailing Address - Phone:720-270-6033
Mailing Address - Fax:
Practice Address - Street 1:4063 W 12600 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-7302
Practice Address - Country:US
Practice Address - Phone:801-495-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12324418-4101231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12343318-4101OtherDOPL