Healthcare Provider Details

I. General information

NPI: 1770437824
Provider Name (Legal Business Name): AUDRA RYSEVAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2026
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 W 2100 S STE 130B
SALT LAKE CITY UT
84115-1854
US

IV. Provider business mailing address

140 W 2100 S STE 130B
SOUTH SALT LAKE UT
84115-1854
US

V. Phone/Fax

Practice location:
  • Phone: 801-896-7930
  • Fax:
Mailing address:
  • Phone: 801-896-1930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberF25-117395
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: