Healthcare Provider Details

I. General information

NPI: 1073243531
Provider Name (Legal Business Name): MEKENNA ANDREE BERMINGHAM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3723 W 12600 S STE 330
RIVERTON UT
84065-7309
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-285-4543
  • Fax: 801-285-4540
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8497877-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number8497877-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: