Healthcare Provider Details

I. General information

NPI: 1376465443
Provider Name (Legal Business Name): AMY DEON NOSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY DEON NOSTROM

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 W COUGAR BLVD STE 503
PROVO UT
84604-3323
US

IV. Provider business mailing address

330 E 350 N
SALEM UT
84653-9492
US

V. Phone/Fax

Practice location:
  • Phone: 801-787-4077
  • Fax: 801-787-4077
Mailing address:
  • Phone: 801-787-4077
  • Fax: 801-787-4077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9106992-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: