MEDICARE: MRS. AMANDA SUE AL-KHUDAIRI MSN, RNC, APRN

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	363LW0102X	Women's Health Nurse Practitioner	372242-4405	UT

General Provider Information

NPI Number	:	1861613242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMANDA SUE AL-KHUDAIRI MSN, RNC, APRN

Provider Business Mailing Address
First Line	:	6900 S 800 E
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-1431
Country	:	US
Telephone Number	:	801-569-9363
Fax Number	:

Provider Business Practice Location Address
First Line	:	1906 W 3600 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84119-4715
Country	:	US
Telephone Number	:	801-973-9675
Fax Number	:

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	10/16/2021

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