Healthcare Provider Details

I. General information

NPI: 1396532065
Provider Name (Legal Business Name): ANDREA TILLOTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA DRUK

II. Dates (important events)

Enumeration Date: 04/24/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-487-0451
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6203483-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: