Healthcare Provider Details

I. General information

NPI: 1275971483
Provider Name (Legal Business Name): JENNIFER NICOLE GRISWOLD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER NICOLE MONDOR-GRISWOLD RN

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 E 4800 S #230
MURRAY UT
84107
US

IV. Provider business mailing address

835 E 4800 S #230
MURRAY UT
84107
US

V. Phone/Fax

Practice location:
  • Phone: 801-716-7008
  • Fax:
Mailing address:
  • Phone: 801-716-7008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberN-43796
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number8736262-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: