Provider Demographics
NPI:1124350137
Name:CUDDEBACK, NICHOLE (CRNA)
Entity type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:
Last Name:CUDDEBACK
Suffix:
Gender:F
Credentials:CRNA
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 3570
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3570
Mailing Address - Country:US
Mailing Address - Phone:801-727-2056
Mailing Address - Fax:770-701-6675
Practice Address - Street 1:9660 S 1300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3762
Practice Address - Country:US
Practice Address - Phone:801-727-2056
Practice Address - Fax:770-701-6675
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168646367500000X, 367500000X
UT3094717-4406367500000X, 367500000X, 163W00000X
UT3094717-8901163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1124350137Medicaid
VA1124350137Medicaid