Healthcare Provider Details

I. General information

NPI: 1366982522
Provider Name (Legal Business Name): YOUNG HEALTH & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 08/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3018 E 3300 S
SALT LAKE CITY UT
84109-2144
US

IV. Provider business mailing address

6321 S BOXWOOD RD
SALT LAKE CITY UT
84121-2213
US

V. Phone/Fax

Practice location:
  • Phone: 801-815-2967
  • Fax:
Mailing address:
  • Phone: 801-815-2967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number53036184405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5303618-4405
License Number StateUT

VIII. Authorized Official

Name: DIANE YOUNG
Title or Position: PROVIDER
Credential: FNP
Phone: 801-815-2967