Healthcare Provider Details

I. General information

NPI: 1720855927
Provider Name (Legal Business Name): TIFFANEE RAE CRAVENS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2023
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13894 S BANGERTER PKWY STE 200
DRAPER UT
84020-5320
US

IV. Provider business mailing address

716 W SUNNY LEDGE DR
WASHINGTON UT
84780-3576
US

V. Phone/Fax

Practice location:
  • Phone: 385-454-5027
  • Fax: 801-742-8381
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11122057-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: