Healthcare Provider Details

I. General information

NPI: 1376360784
Provider Name (Legal Business Name): CLINTON TERRY GILLESPIE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E 3900 S
MILLCREEK UT
84124-1300
US

IV. Provider business mailing address

1119 W 2500 S
SYRACUSE UT
84075-8622
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-7111
  • Fax:
Mailing address:
  • Phone: 424-242-4713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number14153666-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: