Provider Demographics
NPI:1932568854
Name:NUMKENA, NICOLE ILENE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ILENE
Last Name:NUMKENA
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 1:852 E THREE FOUNTAINS DR UNIT 203
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5278
Mailing Address - Country:US
Mailing Address - Phone:801-649-9011
Mailing Address - Fax:
Practice Address - Street 1:852 E THREE FOUNTAINS DR UNIT 203
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5278
Practice Address - Country:US
Practice Address - Phone:801-649-9011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12623886Medicaid