Healthcare Provider Details

I. General information

NPI: 1649851890
Provider Name (Legal Business Name): ANNALISE M. DEANE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNALISE MANLEY

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 1900 E RM 3B324
SALT LAKE CITY UT
84132-0002
US

IV. Provider business mailing address

30 N 1900 E RM 3B324
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-6803
  • Fax:
Mailing address:
  • Phone: 801-581-6803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number12984919-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: