Healthcare Provider Details

I. General information

NPI: 1447939541
Provider Name (Legal Business Name): LEZETTE RUSCH FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 07/17/2023
Certification Date: 07/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4640 S 5675 W
HOOPER UT
84315-3400
US

IV. Provider business mailing address

4640 S 5675 W
HOOPER UT
84315-3400
US

V. Phone/Fax

Practice location:
  • Phone: 801-391-4610
  • Fax:
Mailing address:
  • Phone: 801-391-4610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number8325803-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8325803-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: