Healthcare Provider Details

I. General information

NPI: 1760337885
Provider Name (Legal Business Name): PETER JOSEPH CLANCY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 E 200 N APT 304
PROVO UT
84606-6671
US

IV. Provider business mailing address

73 E 200 N APT 304
PROVO UT
84606-6671
US

V. Phone/Fax

Practice location:
  • Phone: 469-264-4639
  • Fax:
Mailing address:
  • Phone: 469-264-4639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11560202-8900
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: