Healthcare Provider Details

I. General information

NPI: 1558682856
Provider Name (Legal Business Name): TAK WAI KWONG RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 S 500 E
SALT LAKE CITY UT
84102-1002
US

IV. Provider business mailing address

3681 S 1950 W APT 34
SALT LAKE CITY UT
84119-3888
US

V. Phone/Fax

Practice location:
  • Phone: 801-428-3484
  • Fax:
Mailing address:
  • Phone: 801-860-2624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number6829095-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: