Healthcare Provider Details

I. General information

NPI: 1063249688
Provider Name (Legal Business Name): REBECCA J WINGSTER MHA, RN, CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

493 E ELIZABETH DAY CV
DRAPER UT
84020-5189
US

IV. Provider business mailing address

493 E ELIZABETH DAY CV
DRAPER UT
84020-5189
US

V. Phone/Fax

Practice location:
  • Phone: 801-891-6470
  • Fax:
Mailing address:
  • Phone: 801-891-6470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number807986
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number220502-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: