Healthcare Provider Details

I. General information

NPI: 1659251833
Provider Name (Legal Business Name): TANYA MARIE FORSYTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2025
Last Update Date: 09/06/2025
Certification Date: 09/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3197 W 2650 N
CLINTON UT
84015-7798
US

IV. Provider business mailing address

3197 W 2650 N
CLINTON UT
84015-7798
US

V. Phone/Fax

Practice location:
  • Phone: 801-403-3170
  • Fax:
Mailing address:
  • Phone: 801-403-3170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9134993-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: