Healthcare Provider Details

I. General information

NPI: 1811508435
Provider Name (Legal Business Name): COURTNEY WATERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2020
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
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: 801-298-9155
  • Fax: 801-298-9156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12615135-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: