Healthcare Provider Details

I. General information

NPI: 1427235811
Provider Name (Legal Business Name): REBECCA EMILY ENNEN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 ROUND VALLEY DR STE 201
PARK CITY UT
84060-7549
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 435-649-7680
  • Fax: 435-776-9353
Mailing address:
  • Phone: 435-649-7680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP17730
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11273913-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: