MEDICARE: HILARY VERSON RN MS FNP

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	164W00000X	Licensed Practical Nurse	212581-4405	UT

General Provider Information

NPI Number	:	1003119819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HILARY VERSON RN MS FNP

Provider Business Mailing Address
First Line	:	455 EAST SOUTH TEMPLE
Second Line	:	#202
City	:	SLC
State	:	UT
Zip	:	84111-1325
Country	:	US
Telephone Number	:	801-355-9951
Fax Number	:	801-355-9968

Provider Business Practice Location Address
First Line	:	455 EAST SOUTH TEMPLE
Second Line	:	#202
City	:	SLC
State	:	UT
Zip	:	84111-1325
Country	:	US
Telephone Number	:	801-355-9951
Fax Number	:	801-355-9968

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

Provider Enumeration Date	:	12/16/2010
Last Update Date	:	12/21/2010

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