Healthcare Provider Details

I. General information

NPI: 1629210646
Provider Name (Legal Business Name): LIENA M BRADY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 04/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

926 W 1700 S
CLEARFIELD UT
84015-8530
US

IV. Provider business mailing address

1950 E 7000 S
SALT LAKE CITY UT
84121-6894
US

V. Phone/Fax

Practice location:
  • Phone: 801-614-2100
  • Fax: 801-614-2101
Mailing address:
  • Phone: 801-256-0009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number292983-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: