Healthcare Provider Details

I. General information

NPI: 1902574676
Provider Name (Legal Business Name): DANAE MICHELLE TITENSOR APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 N UNIVERSITY AVE STE 250
PROVO UT
84604-6695
US

IV. Provider business mailing address

1263 N 2470 W
PROVO UT
84601-5021
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-9625
  • Fax:
Mailing address:
  • Phone: 801-319-3912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8281304-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number8281304-4405
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8281304-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: