Healthcare Provider Details

I. General information

NPI: 1265861751
Provider Name (Legal Business Name): TINA EARL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5965 S 900 E # EAT
MURRAY UT
84121-1720
US

IV. Provider business mailing address

5965 S 900 E # EAT
MURRAY UT
84121-1720
US

V. Phone/Fax

Practice location:
  • Phone: 801-263-7138
  • Fax:
Mailing address:
  • Phone: 801-263-7138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number188649-3101
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: