Healthcare Provider Details

I. General information

NPI: 1861613242
Provider Name (Legal Business Name): AMANDA SUE AL-KHUDAIRI MSN, RNC, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 10/16/2021
Certification Date: 10/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 W 3600 S
SALT LAKE CITY UT
84119-4715
US

IV. Provider business mailing address

6900 S 800 E
MIDVALE UT
84047-1431
US

V. Phone/Fax

Practice location:
  • Phone: 801-973-9675
  • Fax:
Mailing address:
  • Phone: 801-569-9363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number372242-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: