Healthcare Provider Details

I. General information

NPI: 1104810134
Provider Name (Legal Business Name): REBECCA WALLACE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 S 700 E SUITE 200
SALT LAKE CITY UT
84106-1466
US

IV. Provider business mailing address

1837 HOLLYWOOD AVE
SALT LAKE CITY UT
84108-3103
US

V. Phone/Fax

Practice location:
  • Phone: 801-261-4988
  • Fax: 801-269-9427
Mailing address:
  • Phone: 801-487-4160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number216162-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: