Healthcare Provider Details

I. General information

NPI: 1922593722
Provider Name (Legal Business Name): AUBREY ANN KRUISMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUBREY BOLINDER

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

434 W ASCENSION WAY STE 225
SALT LAKE CITY UT
84123-2790
US

IV. Provider business mailing address

954 N 620 E
TOOELE UT
84074-9825
US

V. Phone/Fax

Practice location:
  • Phone: 801-716-7008
  • Fax:
Mailing address:
  • Phone: 435-224-4288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6991194-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: