Healthcare Provider Details

I. General information

NPI: 1902450687
Provider Name (Legal Business Name): JACE NYE DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 S 500 E STE 204
OGDEN UT
84405-7420
US

IV. Provider business mailing address

PO BOX 741729
ATLANTA GA
30374-1729
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-0184
  • Fax: 801-479-5642
Mailing address:
  • Phone: 801-479-0184
  • Fax: 801-479-5642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9022831-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: