Healthcare Provider Details

I. General information

NPI: 1295529253
Provider Name (Legal Business Name): ALLISON LYNNE BONHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 W BROADWAY STE 333
SALT LAKE CITY UT
84101-2027
US

IV. Provider business mailing address

50 W BROADWAY STE 333
SALT LAKE CITY UT
84101-2027
US

V. Phone/Fax

Practice location:
  • Phone: 385-329-7410
  • Fax:
Mailing address:
  • Phone: 385-329-7410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number6691900-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: