Healthcare Provider Details

I. General information

NPI: 1760885909
Provider Name (Legal Business Name): BREANNE WHEELWRIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 S 1000 E APT 24
CLEARFIELD UT
84015-1637
US

IV. Provider business mailing address

1575 S 1000 E APT 24
CLEARFIELD UT
84015-1637
US

V. Phone/Fax

Practice location:
  • Phone: 801-389-9133
  • Fax:
Mailing address:
  • Phone: 801-389-9133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: