Healthcare Provider Details

I. General information

NPI: 1588015366
Provider Name (Legal Business Name): ELIZABETH THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6112 S 1550 E
OGDEN UT
84405-5007
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-3800
  • Fax: 801-475-3801
Mailing address:
  • Phone: 801-475-3482
  • Fax: 801-475-3494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number81600883102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number81600884405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: