Healthcare Provider Details

I. General information

NPI: 1891151130
Provider Name (Legal Business Name): DIANA ANDERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA JENKINS RN

II. Dates (important events)

Enumeration Date: 12/31/2015
Last Update Date: 12/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6822 E. 1000 S.
FT DUCHESNE UT
84026
US

IV. Provider business mailing address

PO BOX 160
FORT DUCHESNE UT
84026-0160
US

V. Phone/Fax

Practice location:
  • Phone: 435-725-6894
  • Fax:
Mailing address:
  • Phone: 435-725-6894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number8640320-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: