Healthcare Provider Details

I. General information

NPI: 1902534522
Provider Name (Legal Business Name): ASHLY JANE WEIGHT ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 08/11/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BRIGHAM YOUNG UNIVERSITY 1150 N 150 E
PROVO UT
84602
US

IV. Provider business mailing address

BRIGHAM YOUNG UNIVERSITY 1150 N 150 E
PROVO UT
84606
US

V. Phone/Fax

Practice location:
  • Phone: 801-422-4636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number12929506-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: