Healthcare Provider Details

I. General information

NPI: 1265174452
Provider Name (Legal Business Name): JUSTIN ALAN ILLUM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 12/08/2024
Certification Date: 12/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 E CREEKHILL LN APT 10
MIDVALE UT
84047-2365
US

IV. Provider business mailing address

971 E CREEKHILL LN APT 10
MIDVALE UT
84047-2365
US

V. Phone/Fax

Practice location:
  • Phone: 417-693-3850
  • Fax:
Mailing address:
  • Phone: 417-693-3850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10386297-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: