Healthcare Provider Details

I. General information

NPI: 1174892905
Provider Name (Legal Business Name): RENEE HOLLERAN PHD, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9720 S 1300 E STE E240
SANDY UT
84094-3795
US

IV. Provider business mailing address

9720 S 1300 E STE E240
SANDY UT
84094-3795
US

V. Phone/Fax

Practice location:
  • Phone: 801-501-2025
  • Fax: 801-501-4099
Mailing address:
  • Phone: 801-501-2025
  • Fax: 801-501-4099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5377224-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: