Healthcare Provider Details

I. General information

NPI: 1598067811
Provider Name (Legal Business Name): W SUE BEDARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 HARRISON BLVD
OGDEN UT
84403-3195
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-4132
  • Fax:
Mailing address:
  • Phone: 435-716-5848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number192705-9938
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: