Healthcare Provider Details

I. General information

NPI: 1336480920
Provider Name (Legal Business Name): BRENDA STURDEVANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2013
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 N. 200 E.
MOAB UT
84532
US

IV. Provider business mailing address

P.O. BOX 867
PRICE UT
84501-0867
US

V. Phone/Fax

Practice location:
  • Phone: 435-259-7340
  • Fax: 435-678-3116
Mailing address:
  • Phone: 435-637-7200
  • Fax: 435-678-3116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9753121-3503
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: