Healthcare Provider Details

I. General information

NPI: 1629376405
Provider Name (Legal Business Name): HANNELE LAINE, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2011
Last Update Date: 03/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 E SOUTH TEMPLE STE 202
SLC UT
84111-1350
US

IV. Provider business mailing address

455 E SOUTH TEMPLE STE 202
SLC UT
84111-1350
US

V. Phone/Fax

Practice location:
  • Phone: 801-355-9951
  • Fax: 801-355-9968
Mailing address:
  • Phone: 801-355-9951
  • Fax: 801-355-9968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number57672111205
License Number StateUT

VIII. Authorized Official

Name: MRS. JACKIE ANDERSEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-355-9951