Healthcare Provider Details

I. General information

NPI: 1174343784
Provider Name (Legal Business Name): JAQUELINE GASTELUM APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

476 N 900 W STE C
AMERICAN FORK UT
84003-5202
US

IV. Provider business mailing address

10433 S REDWOOD RD STE 2
SOUTH JORDAN UT
84095-8502
US

V. Phone/Fax

Practice location:
  • Phone: 801-492-1611
  • Fax: 801-492-1480
Mailing address:
  • Phone: 801-260-1919
  • Fax: 801-260-1441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9708922-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9708922-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: