Healthcare Provider Details

I. General information

NPI: 1063798403
Provider Name (Legal Business Name): WASATCH NURSE PRACTITIONER SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2011
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3683 WILDROSE LN
SALT LAKE CITY UT
84109-4324
US

IV. Provider business mailing address

3683 WILDROSE LN
SALT LAKE CITY UT
84109-4324
US

V. Phone/Fax

Practice location:
  • Phone: 801-918-9793
  • Fax:
Mailing address:
  • Phone: 801-918-9793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1166904405
License Number StateUT

VIII. Authorized Official

Name: DR. SANDRA W BAGLEY
Title or Position: OWNER
Credential: FNP
Phone: 801-918-9793