Healthcare Provider Details

I. General information

NPI: 1104277664
Provider Name (Legal Business Name): HEATHER WILES BAGLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 08/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 S COTTONWOOD ST
MURRAY UT
84107-5701
US

IV. Provider business mailing address

5121 S COTTONWOOD ST
MURRAY UT
84107-5701
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3975
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: