Healthcare Provider Details

I. General information

NPI: 1639921117
Provider Name (Legal Business Name): MCKENZIE ANNE WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2024
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
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

433 N STEIN WAY
LAYTON UT
84040-8701
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-4000
  • Fax:
Mailing address:
  • Phone: 801-726-8796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number124101293102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number124101293102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: