Healthcare Provider Details

I. General information

NPI: 1023784741
Provider Name (Legal Business Name): WENDY SUSAETA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2021
Last Update Date: 08/22/2021
Certification Date: 08/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 W 6300 S
MURRAY UT
84123-6846
US

IV. Provider business mailing address

689 W 6300 S
MURRAY UT
84123-6846
US

V. Phone/Fax

Practice location:
  • Phone: 801-450-7122
  • Fax:
Mailing address:
  • Phone: 801-450-7122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number273350-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: