Healthcare Provider Details

I. General information

NPI: 1952036261
Provider Name (Legal Business Name): MATTHEW BRENT TALLEY FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3665 S 8400 W STE 110
MAGNA UT
84044-4907
US

IV. Provider business mailing address

4133 W PIONEER PKWY STE 100
WEST VALLEY CITY UT
84120-2059
US

V. Phone/Fax

Practice location:
  • Phone: 801-250-9638
  • Fax:
Mailing address:
  • Phone: 801-250-9638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN278964
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12935592-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: