Healthcare Provider Details

I. General information

NPI: 1558975946
Provider Name (Legal Business Name): MALLORY SARGEANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

857 E 200 S
SALT LAKE CITY UT
84102-2317
US

IV. Provider business mailing address

857 E 200 S
SALT LAKE CITY UT
84102-2317
US

V. Phone/Fax

Practice location:
  • Phone: 801-487-3276
  • Fax:
Mailing address:
  • Phone: 801-487-3276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: