Healthcare Provider Details

I. General information

NPI: 1356642094
Provider Name (Legal Business Name): EMMALEE THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 11/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5475 S 500 E
OGDEN UT
84405-6905
US

IV. Provider business mailing address

3577 WING POINT DR
MAGNA UT
84044-2478
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-2550
  • Fax:
Mailing address:
  • Phone: 801-250-6922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4784779-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: