Healthcare Provider Details

I. General information

NPI: 1326438664
Provider Name (Legal Business Name): LISA TEII VELLINGA RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N MAIN ST
RICHFIELD UT
84701-2061
US

IV. Provider business mailing address

1000 N MAIN
RICHFIELD UT
84701
US

V. Phone/Fax

Practice location:
  • Phone: 435-893-0640
  • Fax: 435-893-0630
Mailing address:
  • Phone: 435-893-0640
  • Fax: 435-893-0630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number295149-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: