Healthcare Provider Details

I. General information

NPI: 1801413000
Provider Name (Legal Business Name): RAQUEL BATRICE RUGGIERO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2020
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 GOLF COURSE RD STE E
LOGAN UT
84321-5934
US

IV. Provider business mailing address

319 N 200 E
LOGAN UT
84321-4010
US

V. Phone/Fax

Practice location:
  • Phone: 435-999-4059
  • Fax: 435-213-2800
Mailing address:
  • Phone: 661-618-2568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95018355
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number13194783-4405
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: