Healthcare Provider Details

I. General information

NPI: 1386441996
Provider Name (Legal Business Name): TEGAN GRUNWALD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2025
Last Update Date: 09/11/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 E LION LN STE 160
SALT LAKE CITY UT
84121
US

IV. Provider business mailing address

2177 S NOWELL CIR
SALT LAKE CITY UT
84115-2869
US

V. Phone/Fax

Practice location:
  • Phone: 855-255-1750
  • Fax: 855-255-0905
Mailing address:
  • Phone: 541-760-0032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12627832-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: