Healthcare Provider Details

I. General information

NPI: 1811179088
Provider Name (Legal Business Name): OLIVE SEIN KONANA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 HARRISON BLVD
OGDEN UT
84403
US

IV. Provider business mailing address

PO BOX 27128
SLC UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-4300
  • Fax:
Mailing address:
  • Phone: 801-387-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10219168-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number01066198
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: