Healthcare Provider Details

I. General information

NPI: 1831773449
Provider Name (Legal Business Name): ANGALA DEE BRYSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1262 FIR AVE
ROOSEVELT UT
84066-3820
US

IV. Provider business mailing address

1262 FIR AVE
ROOSEVELT UT
84066-3820
US

V. Phone/Fax

Practice location:
  • Phone: 801-455-7492
  • Fax:
Mailing address:
  • Phone: 801-455-7492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8026005-8900
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8026005-4405
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number8026005-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: