MEDICARE: DR. CRYSTAL BRENNEN WALLENTINE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	3613633-1205	UT

General Provider Information

NPI Number	:	1003060815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CRYSTAL BRENNEN WALLENTINE M.D.

Provider Business Mailing Address
First Line	:	1937 E SAINT MARYS DR
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84108-2245
Country	:	US
Telephone Number	:	801-865-0549
Fax Number	:

Provider Business Practice Location Address
First Line	:	1937 E SAINT MARYS DR
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84108-2245
Country	:	US
Telephone Number	:	801-865-0549
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2008
Last Update Date	:	01/07/2023

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