Healthcare Provider Details

I. General information

NPI: 1558778902
Provider Name (Legal Business Name): BOZENA BEATA MONTES AGNP, ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3802 S 700 E
SALT LAKE CITY UT
84106-1182
US

IV. Provider business mailing address

15024 S ROSE CREEK LN
HERRIMAN UT
84096-3639
US

V. Phone/Fax

Practice location:
  • Phone: 801-264-6000
  • Fax: 801-564-6098
Mailing address:
  • Phone: 773-653-9622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11334524-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number11334524-4405
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number11334524-4405
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number11334524-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: