Healthcare Provider Details

I. General information

NPI: 1649627761
Provider Name (Legal Business Name): REN CHILD FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 HARRISON BLVD
OGDEN UT
84403-4303
US

IV. Provider business mailing address

9900 BREN ROAD EAST MAIL ROUTE MN 008-B213
MINNETONKA MN
55343
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-3300
  • Fax: 801-475-3301
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number7805009-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7805009-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: