Healthcare Provider Details

I. General information

NPI: 1932874591
Provider Name (Legal Business Name): JESSICA LAKE ROSEMANN APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2021
Last Update Date: 08/14/2021
Certification Date: 08/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 ASHLEY CIR
BOUNTIFUL UT
84010-3206
US

IV. Provider business mailing address

911 ASHLEY CIR
BOUNTIFUL UT
84010-3206
US

V. Phone/Fax

Practice location:
  • Phone: 801-884-3280
  • Fax:
Mailing address:
  • Phone: 801-884-3280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5905489-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: