Healthcare Provider Details

I. General information

NPI: 1487330700
Provider Name (Legal Business Name): KRISTINE GEBAUER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S ARAPEEN DR
SALT LAKE CITY UT
84108-1267
US

IV. Provider business mailing address

30 N 1900 E
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7246
  • Fax:
Mailing address:
  • Phone: 801-581-6393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8891112-4408
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: