Healthcare Provider Details

I. General information

NPI: 1477091684
Provider Name (Legal Business Name): HALEY MICHELLE VANDERHILL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 S WAKARA WAY
SALT LAKE CITY UT
84108-1200
US

IV. Provider business mailing address

30 N ORANGE ST UNIT A316
SALT LAKE CITY UT
84116-3938
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-1272
  • Fax:
Mailing address:
  • Phone: 414-617-3807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: