Healthcare Provider Details

I. General information

NPI: 1215027842
Provider Name (Legal Business Name): MIRIAM BEATTIE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 1900 E SALT LAKE CITY
SALT LAKE CITY UT
84132-0006
US

IV. Provider business mailing address

30 N 1900 E SALT LAKE CITY
SALT LAKE CITY UT
84132-0006
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-9103
  • Fax:
Mailing address:
  • Phone: 801-587-9103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number200049-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number200049-4405
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number200049-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: