Healthcare Provider Details

I. General information

NPI: 1508709460
Provider Name (Legal Business Name): RYLEE PETERSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12760 S PARK AVE UNIT 520
RIVERTON UT
84065-3422
US

IV. Provider business mailing address

2946 W 3450 N
FARR WEST UT
84404-8616
US

V. Phone/Fax

Practice location:
  • Phone: 801-407-0047
  • Fax: 888-400-9232
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number14201933-3503
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: