Healthcare Provider Details

I. General information

NPI: 1063093326
Provider Name (Legal Business Name): MEGAN MARIE WALTERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 W 2600 S
BOUNTIFUL UT
84010-7717
US

IV. Provider business mailing address

557 W 2600 S
BOUNTIFUL UT
84010-7717
US

V. Phone/Fax

Practice location:
  • Phone: 801-298-9155
  • Fax: 801-298-9156
Mailing address:
  • Phone: 801-299-8260
  • Fax: 801-298-9156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9818046-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9818046-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: