Healthcare Provider Details

I. General information

NPI: 1093480584
Provider Name (Legal Business Name): BRADES' PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 08/16/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 S PALISADES DR
OREM UT
84097-6694
US

IV. Provider business mailing address

417 S PALISADES DR
OREM UT
84097-6694
US

V. Phone/Fax

Practice location:
  • Phone: 801-368-4499
  • Fax:
Mailing address:
  • Phone: 801-368-4499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: REBECCA RAE OAKLEY
Title or Position: EXECUTIVE DIRECTOR
Credential: FNP
Phone: 801-368-4499