Healthcare Provider Details

I. General information

NPI: 1487643011
Provider Name (Legal Business Name): KAREN S VASTARDIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1159 E 12TH ST
OGDEN UT
84404-5144
US

IV. Provider business mailing address

4650 HARRISON BLVD
OGDEN UT
84403-4303
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-3700
  • Fax: 801-475-3701
Mailing address:
  • Phone: 801-475-3000
  • Fax: 801-475-3414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number344892-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: