Healthcare Provider Details

I. General information

NPI: 1346776184
Provider Name (Legal Business Name): TAYLA RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 W 600 N
MANTUA UT
84324-4398
US

IV. Provider business mailing address

6556 S BIG COTTONWOOD CYN SUITE #300
HOLLADAY UT
84121-3580
US

V. Phone/Fax

Practice location:
  • Phone: 435-553-5698
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: