Healthcare Provider Details

I. General information

NPI: 1497439178
Provider Name (Legal Business Name): TRACIE K WECKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2023
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 HERITAGE PARK BLVD STE 4
LAYTON UT
84041-5611
US

IV. Provider business mailing address

523 HERITAGE PARK BLVD STE 4
LAYTON UT
84041-5611
US

V. Phone/Fax

Practice location:
  • Phone: 801-525-9998
  • Fax:
Mailing address:
  • Phone: 801-525-9998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number211810-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: