Healthcare Provider Details

I. General information

NPI: 1659182947
Provider Name (Legal Business Name): VALLEY MOBILE WOUND CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1288 DEVONSHIRE DR.
PROVO UT
84604
US

IV. Provider business mailing address

1288 DEVONSHIRE DR.
PROVO UT
84604
US

V. Phone/Fax

Practice location:
  • Phone: 801-664-7688
  • Fax:
Mailing address:
  • Phone: 801-664-7688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRADY EWING
Title or Position: OWNER
Credential:
Phone: 845-543-5211