Healthcare Provider Details

I. General information

NPI: 1154649077
Provider Name (Legal Business Name): GRANTSVILLE HEALTH & WELLNESS CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 05/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 W APPLE ST
GRANTSVILLE UT
84029-9635
US

IV. Provider business mailing address

271 E BROADWAY ST
TOOELE UT
84074-3116
US

V. Phone/Fax

Practice location:
  • Phone: 435-843-9964
  • Fax: 435-843-9964
Mailing address:
  • Phone: 435-843-9964
  • Fax: 435-843-9964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number288698-4405
License Number StateUT

VIII. Authorized Official

Name: MS. KATHERINE E. DEVRIES
Title or Position: OWNER/PROVIDER
Credential: APRN
Phone: 435-843-9964