Healthcare Provider Details

I. General information

NPI: 1649398694
Provider Name (Legal Business Name): INEZ B WITHERS PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 N COMMERCIAL ST
MORGAN UT
84050-9570
US

IV. Provider business mailing address

PO BOX 27
MORGAN UT
84050-0027
US

V. Phone/Fax

Practice location:
  • Phone: 256-425-7884
  • Fax:
Mailing address:
  • Phone: 256-425-7884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number1-095255
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number106663828900
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: