Healthcare Provider Details

I. General information

NPI: 1104622158
Provider Name (Legal Business Name): BRYNNA HADDOCK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRYNNA WILSON

II. Dates (important events)

Enumeration Date: 02/20/2025
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 500 W STE 222
PROVO UT
84604-3305
US

IV. Provider business mailing address

1055 N 500 W ATTN: CREDENTIALING
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-354-8225
  • Fax: 801-418-0941
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14205405-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number14205405-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: