Healthcare Provider Details

I. General information

NPI: 1396499414
Provider Name (Legal Business Name): WASATCH FUNCTIONAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5711 S 1475 E STE 201
SOUTH OGDEN UT
84403-5185
US

IV. Provider business mailing address

5711 S 1475 E STE 201
SOUTH OGDEN UT
84403-5185
US

V. Phone/Fax

Practice location:
  • Phone: 801-332-9034
  • Fax:
Mailing address:
  • Phone: 801-332-9034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CATHERINE KELLY PIERCE
Title or Position: OWNER/NURSE PRACTITIONER
Credential: FNP-C
Phone: 801-332-9034