Healthcare Provider Details

I. General information

NPI: 1144010315
Provider Name (Legal Business Name): AMANDA DUSTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2025
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W 465 N # 601
PROVIDENCE UT
84332-8006
US

IV. Provider business mailing address

560 W 465 N # 601
PROVIDENCE UT
84332-8006
US

V. Phone/Fax

Practice location:
  • Phone: 801-515-5564
  • Fax:
Mailing address:
  • Phone: 801-515-5564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number11770648-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11770648-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: