Healthcare Provider Details

I. General information

NPI: 1780577189
Provider Name (Legal Business Name): SELENE INGRAHAM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 500 W STE 201 BLDG C
PROVO UT
84604
US

IV. Provider business mailing address

1055 N 500 W ATTN CREDENTIALING
PROVO UT
84604
US

V. Phone/Fax

Practice location:
  • Phone: 801-429-8000
  • Fax: 801-429-8150
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8513908-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: