Healthcare Provider Details

I. General information

NPI: 1538495262
Provider Name (Legal Business Name): GAYLENE O WALL CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GAYLENE O BROWN CNA

II. Dates (important events)

Enumeration Date: 10/30/2009
Last Update Date: 10/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6393 W 4600 S
HOOPER UT
84315-6753
US

IV. Provider business mailing address

6393 W 4600 S
HOOPER UT
84315-6753
US

V. Phone/Fax

Practice location:
  • Phone: 801-985-7585
  • Fax:
Mailing address:
  • Phone: 801-985-7585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberUT000212840909
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberUT000212840909
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: