Healthcare Provider Details

I. General information

NPI: 1265715643
Provider Name (Legal Business Name): CALLENE BOBO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E 100 N
PAYSON UT
84651-1600
US

IV. Provider business mailing address

1000 E 100 N
PAYSON UT
84651-1600
US

V. Phone/Fax

Practice location:
  • Phone: 801-465-7745
  • Fax: 801-465-7044
Mailing address:
  • Phone: 801-465-7745
  • Fax: 801-465-7044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number197177-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: