Individual
NIKOLE DECKER SQUIRES
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LAT, ATC, CPT
Contact information
Practice address
6748 W 9500 N, HIGHLAND, UT 84003-3455
(480) 318-3949
Mailing address
290 N 1260 W, PROVO, UT 84601-2436
(480) 318-3949
Taxonomy
Speciality
Code
Description
License number
State
2081S0010X
Sports Medicine (Physical Medicine & Rehabilitation) Physician
10877423-4810
UT
2083S0010X
Sports Medicine (Preventive Medicine) Physician
10877423-4810
UT
2255A2300X
Athletic Trainer
Primary
10877423-4810
UT
405300000X
Prevention Professional
TBA
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10877423-4810
UT DIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING
UT
01
—
2000031617
NATIONAL ATHLETIC TRAINERS' ASSOCIATION BOARD OF CERTIFICATION, INC.
—
01
—
TBA
NATIONAL ACADEMY OF SPORTS MEDICINE
—
Enumeration date
02/19/2019
Last updated
02/19/2019
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