Healthcare Provider Details

I. General information

NPI: 1770070260
Provider Name (Legal Business Name): EASTERN UTAH WOMENS HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 S 600 E STE B
PRICE UT
84501-3174
US

IV. Provider business mailing address

PO BOX 656
PRICE UT
84501-0656
US

V. Phone/Fax

Practice location:
  • Phone: 435-637-0313
  • Fax: 435-637-0317
Mailing address:
  • Phone: 435-637-0313
  • Fax: 435-637-0317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number3196374405
License Number StateUT

VIII. Authorized Official

Name: DANIELLE PENDERGRASS
Title or Position: PRESIDENT
Credential: DNP, APRN, WHNP-BC
Phone: 435-637-0313