Healthcare Provider Details

I. General information

NPI: 1780067561
Provider Name (Legal Business Name): JESSICA MITCHELL A.P.R.N
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 S 900 E
SLC UT
84102-2310
US

IV. Provider business mailing address

6572 S IVORY CIR
TAYLORSVILLE UT
84129-6802
US

V. Phone/Fax

Practice location:
  • Phone: 385-282-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7730292-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: