Healthcare Provider Details

I. General information

NPI: 1285430207
Provider Name (Legal Business Name): NORTHERN VALLEY FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2025
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 N 400 E STE A
LOGAN UT
84341-7539
US

IV. Provider business mailing address

415 W 3400 S
NIBLEY UT
84321-6461
US

V. Phone/Fax

Practice location:
  • Phone: 435-753-2840
  • Fax: 435-787-9422
Mailing address:
  • Phone: 801-557-5024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY LYNN TAGG
Title or Position: OWNER
Credential: FNP
Phone: 801-557-5024