Mark Roland Nickle, FNP

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

6234684-4405 Issued in UT

Practice address

5305 S 1900 W
Roy, UT 84067-2906

Phone

(801) 825-5648

NPI assigned

Jan 15, 2020

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Interoperability endpoints

• FHIR API: https://api.platform.athenahealth.com/19427/brand/1/csg/1/fhir/r4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Utah Kidney Clinic LLC

  • Nephrology Physician
  • Ogden, UT
  • NPI 1013520154
  NPD
• Liberty Dialysis-Woods Cross LLC

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Woods Cross, UT
  • NPI 1396924957
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1579046400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1622073600000",
    "number": "1134769342",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "249 S 1050 E",
            "city": "LAYTON",
            "state": "UT",
            "postal_code": "840414499",
            "telephone_number": "801-663-3126"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5305 S 1900 W",
            "city": "ROY",
            "state": "UT",
            "postal_code": "840672906",
            "telephone_number": "801-825-5648"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3702 S State St Ste 107",
            "address_purpose": "LOCATION",
            "city": "South Salt Lake",
            "state": "UT",
            "postal_code": "841155096",
            "country_code": "US",
            "telephone_number": "801-288-2634",
            "fax_number": "801-288-1186",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "NICKLE",
        "first_name": "MARK",
        "middle_name": "ROLAND",
        "credential": "FNP",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2020-01-15",
        "last_updated": "2021-05-27",
        "certification_date": "2021-05-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "UT",
            "license": "6234684-4405",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "UT",
            "license": "6234684-4405",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1134769342",
            "state": "UT"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "mark.nickle.1@14360.direct.athenahealth.com",
            "affiliation": "N",
            "address_1": "3702 S State St Ste 107",
            "city": "South Salt Lake",
            "state": "UT",
            "country_code": "US",
            "postal_code": "841155096",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Jonathan William Nelson, DMD
• Tausha Nelson
• Daniel Neumann, M.D.
• Linh Nguyen
• Alexandra Nicholas
• James L Nielsen, RPH
• Malia Nixon
• Aylssa Nuglene
• Lara L Nye, PHARMD
• Shalee Nye

• Family Nurse Practitioner in Roy, UT
• Providers in Roy, UT by specialty
• Family Nurse Practitioner in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 27, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.