Healthcare Provider Details

I. General information

NPI: 1194239053
Provider Name (Legal Business Name): AMY JEAN BLEAK APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 N PAIUTE DR
CEDAR CITY UT
84721-6181
US

IV. Provider business mailing address

2484 W MEADOW ST
CEDAR CITY UT
84720-2265
US

V. Phone/Fax

Practice location:
  • Phone: 435-865-1520
  • Fax: 435-867-2658
Mailing address:
  • Phone: 435-592-4307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number345563-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: