Healthcare Provider Details

I. General information

NPI: 1073452074
Provider Name (Legal Business Name): ROXANNE LEWALLEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11616 S STATE ST STE 1501
DRAPER UT
84020-7125
US

IV. Provider business mailing address

11616 S STATE ST STE 1501
DRAPER UT
84020-7125
US

V. Phone/Fax

Practice location:
  • Phone: 801-903-7479
  • Fax:
Mailing address:
  • Phone: 801-903-7479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number8409727-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: