Healthcare Provider Details

I. General information

NPI: 1326523358
Provider Name (Legal Business Name): TIMOTHY LYLE SELLERS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 03/07/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 W COUGAR BLVD STE 602
PROVO UT
84604-3331
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-257-7250
  • Fax:
Mailing address:
  • Phone: 801-373-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9186424-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: