Individual
DR. NICOLE I MEDINA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PSYD
Contact information
Practice address
5965 S 900 E, MURRAY, UT 84121-1757
(801) 872-5516
Mailing address
5965 S 900 E STE 100, MURRAY, UT 84121-1850
(801) 872-5516
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
10158726-2501
UT
103TC0700X
Clinical Psychologist
Primary
10158726-2501
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10158726-2501
PROFESSIONAL LICENSE
UT
05
—
1235488008
—
UT
Enumeration date
09/07/2012
Last updated
08/11/2023
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