Healthcare Provider Details

I. General information

NPI: 1407321219
Provider Name (Legal Business Name): ANNE GRY WHEATON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 E EDITH AVE
SALT LAKE CITY UT
84111-4706
US

IV. Provider business mailing address

375 S CHIPETA WAY
SALT LAKE CITY UT
84108-1260
US

V. Phone/Fax

Practice location:
  • Phone: 253-341-3390
  • Fax:
Mailing address:
  • Phone: 253-341-3390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11480900-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: