Healthcare Provider Details

I. General information

NPI: 1083675649
Provider Name (Legal Business Name): LORI A TEEM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W 300 N 75-3
ROOSEVELT UT
84066
US

IV. Provider business mailing address

PO BOX 238
DUCHESNE UT
84021-0238
US

V. Phone/Fax

Practice location:
  • Phone: 435-722-3971
  • Fax: 435-722-6104
Mailing address:
  • Phone: 435-722-3971
  • Fax: 435-722-6104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2159994405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: