Provider Demographics
NPI:1538830989
Name:GREENE, NICOLE MARIE (APRN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:GREENE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 W BLAZER LN
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-1290
Mailing Address - Country:US
Mailing Address - Phone:435-840-8918
Mailing Address - Fax:
Practice Address - Street 1:12921 S VISTA STATION BLVD
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-2376
Practice Address - Country:US
Practice Address - Phone:435-354-9746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8483463-4405363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT8483463-4405OtherAPRN LICENSE