Healthcare Provider Details

I. General information

NPI: 1568538528
Provider Name (Legal Business Name): ROBERTA ANN LUCAS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 E 4800 S
MURRAY UT
84107-5040
US

IV. Provider business mailing address

8144 S OAK CREEK DR
SANDY UT
84093-6515
US

V. Phone/Fax

Practice location:
  • Phone: 801-622-5418
  • Fax:
Mailing address:
  • Phone: 801-891-3680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number225-249-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number225-249-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: