Provider Demographics
NPI:1184159022
Name:VAN TASSELL, NICOLE LEE
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LEE
Last Name:VAN TASSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1496 EAST 5600 SOUTH
Mailing Address - Street 2:UNIT 6
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403
Mailing Address - Country:US
Mailing Address - Phone:801-479-7026
Mailing Address - Fax:801-479-7134
Practice Address - Street 1:1496 EAST 5600 SOUTH
Practice Address - Street 2:UNIT 6
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403
Practice Address - Country:US
Practice Address - Phone:801-479-7026
Practice Address - Fax:801-479-7134
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT82-1257775253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care