Healthcare Provider Details

I. General information

NPI: 1356080071
Provider Name (Legal Business Name): YIKANEE BAH SAMPSON RN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 06/01/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 S 300 W
BLANDING UT
84511-3921
US

IV. Provider business mailing address

PO BOX 23
BLUFF UT
84512-0023
US

V. Phone/Fax

Practice location:
  • Phone: 435-678-0700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number8749247-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: