Healthcare Provider Details

I. General information

NPI: 1770915852
Provider Name (Legal Business Name): HEATHER SPENCER JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2013
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S ARAPEEN DR STE 100
SALT LAKE CITY UT
84108-1239
US

IV. Provider business mailing address

417 E PIONEER AVE
SANDY UT
84070-1174
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7761
  • Fax:
Mailing address:
  • Phone: 801-918-5480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number7294637-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number7294637-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: