Healthcare Provider Details

I. General information

NPI: 1518584655
Provider Name (Legal Business Name): MAITE ANTOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2020
Last Update Date: 10/13/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 N OREM BLVD
OREM UT
84057-8813
US

IV. Provider business mailing address

421 N OREM BLVD
OREM UT
84057-8813
US

V. Phone/Fax

Practice location:
  • Phone: 801-764-0200
  • Fax: 801-764-0206
Mailing address:
  • Phone: 801-764-0200
  • Fax: 801-764-0206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11971127-1206
License Number StateUT

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: