Healthcare Provider Details

I. General information

NPI: 1710587332
Provider Name (Legal Business Name): SANDRA LANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2020
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5974 FASHION POINT DR STE 110
OGDEN UT
84403-4712
US

IV. Provider business mailing address

5974 FASHION POINT DR STE 110
OGDEN UT
84403-4712
US

V. Phone/Fax

Practice location:
  • Phone: 801-917-2270
  • Fax: 385-831-2987
Mailing address:
  • Phone: 801-917-2270
  • Fax: 385-831-2987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number98524853102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3852485-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: