Provider Demographics
NPI:1114813458
Name:SORENSEN, NICOLE ELISE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELISE
Last Name:SORENSEN
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 1:3472 W SEEFELD CT
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-6917
Mailing Address - Country:US
Mailing Address - Phone:385-630-0531
Mailing Address - Fax:
Practice Address - Street 1:10507 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8504
Practice Address - Country:US
Practice Address - Phone:801-446-9984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12460651-1702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist