Healthcare Provider Details

I. General information

NPI: 1104232834
Provider Name (Legal Business Name): MATTHEW KANENWISHER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 N 680 W
AMERICAN FORK UT
84003-3103
US

IV. Provider business mailing address

464 N 680 W
AMERICAN FORK UT
84003-3103
US

V. Phone/Fax

Practice location:
  • Phone: 801-369-1709
  • Fax:
Mailing address:
  • Phone: 801-369-1709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number8274851-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: