Healthcare Provider Details

I. General information

NPI: 1528517703
Provider Name (Legal Business Name): MRS. REBECCA RAE NIELSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 N 500 E
OREM UT
84097-4124
US

IV. Provider business mailing address

456 N 500 E
OREM UT
84097-4124
US

V. Phone/Fax

Practice location:
  • Phone: 801-722-9491
  • Fax:
Mailing address:
  • Phone: 801-722-9491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: