Healthcare Provider Details

I. General information

NPI: 1649944646
Provider Name (Legal Business Name): BROOKE BUNKALL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 W 2100 S
SALT LAKE CITY UT
84119-1407
US

IV. Provider business mailing address

881 E MAPLE VIEW DR APT 12
MILLCREEK UT
84106-1924
US

V. Phone/Fax

Practice location:
  • Phone: 801-213-9900
  • Fax: 801-213-9910
Mailing address:
  • Phone: 801-915-9104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10849825-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10849825-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: