Provider Demographics
NPI:1902450687
Name:NYE, JACE (DNP)
Entity Type:Individual
Prefix:
First Name:JACE
Middle Name:
Last Name:NYE
Suffix:
Gender:M
Credentials:DNP
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 741729
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1729
Mailing Address - Country:US
Mailing Address - Phone:801-479-0184
Mailing Address - Fax:801-479-5642
Practice Address - Street 1:5405 S 500 E STE 204
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-7420
Practice Address - Country:US
Practice Address - Phone:801-479-0184
Practice Address - Fax:801-479-5642
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9022831-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1437446168Medicaid