MEDICARE: RE'NINA STATEN

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1235962705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RE'NINA STATEN

Provider Business Mailing Address
First Line	:	4001 S 700 E STE 700
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-2533
Country	:	US
Telephone Number	:	801-274-3280
Fax Number	:

Provider Business Practice Location Address
First Line	:	4001 S 700 E STE 700
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-2533
Country	:	US
Telephone Number	:	801-274-3280
Fax Number	:

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

Provider Enumeration Date	:	08/21/2024
Last Update Date	:	08/21/2024

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Directions to “ RE'NINA STATEN ” Practice Location

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