Healthcare Provider Details

I. General information

NPI: 1225664667
Provider Name (Legal Business Name): EMILY KAY DETTENMAIER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E 9400 S STE 101
SANDY UT
84094-4114
US

IV. Provider business mailing address

1512 N 1285 W
OREM UT
84057-6536
US

V. Phone/Fax

Practice location:
  • Phone: 385-449-0565
  • Fax:
Mailing address:
  • Phone: 801-669-4467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number322496-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: