Healthcare Provider Details

I. General information

NPI: 1528296928
Provider Name (Legal Business Name): PEGGY GRUSENDORF APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 06/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E CENTER ST
PROVO UT
84606-3554
US

IV. Provider business mailing address

1300 E CENTER ST
PROVO UT
84606-3554
US

V. Phone/Fax

Practice location:
  • Phone: 801-344-4204
  • Fax: 801-344-4291
Mailing address:
  • Phone: 801-344-4204
  • Fax: 801-344-4291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2057812073
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: