Healthcare Provider Details

I. General information

NPI: 1326735812
Provider Name (Legal Business Name): PHILOMINA EBERE OBAH NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 08/24/2024
Certification Date: 08/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 W 200 N STE 7
KAYSVILLE UT
84037-1873
US

IV. Provider business mailing address

149 EASTFORK CIR
FARMINGTON UT
84025-2672
US

V. Phone/Fax

Practice location:
  • Phone: 801-546-1300
  • Fax: 801-546-1301
Mailing address:
  • Phone: 801-641-3691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number90455463102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9045546-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: