Healthcare Provider Details

I. General information

NPI: 1194450411
Provider Name (Legal Business Name): MESHA FAGG RDN CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 W GORDON AVE STE 1
LAYTON UT
84041-5728
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-397-6150
  • Fax: 801-397-6151
Mailing address:
  • Phone: 801-475-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number292168-4901
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: