Healthcare Provider Details

I. General information

NPI: 1841249380
Provider Name (Legal Business Name): NANCY W. MORTENSEN A.P.R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 09/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 N 500 W
PROVO UT
84604-3380
US

IV. Provider business mailing address

1121 E 3900 S SUITE C-240
SALT LAKE CITY UT
84124-1214
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-8200
  • Fax: 801-357-8201
Mailing address:
  • Phone: 801-266-0878
  • Fax: 801-266-2074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number220619-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: