Provider Demographics
NPI:1366985400
Name:REISS, NICOLETTE JANE
Entity type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:JANE
Last Name:REISS
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 1:58 E MUTTON HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-1257
Mailing Address - Country:US
Mailing Address - Phone:385-240-7700
Mailing Address - Fax:
Practice Address - Street 1:7601 S REDWOOD RD
Practice Address - Street 2:E
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-4007
Practice Address - Country:US
Practice Address - Phone:801-233-8670
Practice Address - Fax:801-233-8682
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program