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: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 CHAMBERS ST STE 200
OGDEN UT
84403-4519
US

IV. Provider business mailing address

955 CHAMBERS ST STE 200
OGDEN UT
84403-4519
US

V. Phone/Fax

Practice location:
  • Phone: 801-252-6774
  • Fax: 801-515-0165
Mailing address:
  • Phone: 801-252-6774
  • Fax: 801-515-0165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3852485-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: