Healthcare Provider Details

I. General information

NPI: 1164501631
Provider Name (Legal Business Name): DEBRA LYNN SANDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 11/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

PO BOX 413021
SALT LAKE CITY UT
84141-3021
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7609
  • Fax:
Mailing address:
  • Phone: 801-213-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number272893-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number272893-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: