Healthcare Provider Details

I. General information

NPI: 1457724452
Provider Name (Legal Business Name): CARRIE ANN BEZZANT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARRIE ANN HANSON ATC

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 E WOODLAKE DR APT 125
SALT LAKE CITY UT
84107-1862
US

IV. Provider business mailing address

370 E WOODLAKE DR APT 125
SALT LAKE CITY UT
84107-1862
US

V. Phone/Fax

Practice location:
  • Phone: 801-699-9926
  • Fax:
Mailing address:
  • Phone: 801-699-9926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number6922421-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: