Provider Demographics
NPI:1942550561
Name:STEPHENS, NICOLE MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:BARRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:5522 S 1025 E
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-7074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5974 FASHION POINT DR
Practice Address - Street 2:#100
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4699
Practice Address - Country:US
Practice Address - Phone:801-479-9644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8167861-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant