Healthcare Provider Details

I. General information

NPI: 1821072448
Provider Name (Legal Business Name): NANCY LEE THACKER RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 E 3900 S
SALT LAKE CITY UT
84124-1215
US

IV. Provider business mailing address

823 W 1440 N
OREM UT
84057-2952
US

V. Phone/Fax

Practice location:
  • Phone: 801-284-4990
  • Fax: 801-284-4991
Mailing address:
  • Phone: 801-270-6517
  • Fax: 801-284-4991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number1960183102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: