Healthcare Provider Details

I. General information

NPI: 1619794625
Provider Name (Legal Business Name): SAMANTHA MICHELLE PRIMAVERA APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2024
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9280 S SHAD LN
SANDY UT
84093-2668
US

IV. Provider business mailing address

9280 S SHAD LN
SANDY UT
84093-2668
US

V. Phone/Fax

Practice location:
  • Phone: 801-502-3166
  • Fax:
Mailing address:
  • Phone: 801-502-3166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number6217771-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: