Healthcare Provider Details

I. General information

NPI: 1073027884
Provider Name (Legal Business Name): KIM DAWN SANDROCK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7906 S 965 E
SANDY UT
84094-0218
US

IV. Provider business mailing address

7906 S 965 E
SANDY UT
84094-0218
US

V. Phone/Fax

Practice location:
  • Phone: 385-214-9759
  • Fax:
Mailing address:
  • Phone: 385-214-9759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number4926588-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: