Healthcare Provider Details

I. General information

NPI: 1922550060
Provider Name (Legal Business Name): LESLIE DIANE PUTNAM APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 500 W STE 205
PROVO UT
84604-3305
US

IV. Provider business mailing address

1905 S VINCENT RIDGE DR
SPANISH FORK UT
84660-8527
US

V. Phone/Fax

Practice location:
  • Phone: 801-429-8095
  • Fax: 801-354-8265
Mailing address:
  • Phone: 801-518-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number217006-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: