Healthcare Provider Details

I. General information

NPI: 1215285374
Provider Name (Legal Business Name): MENERVA YOLE-LOBE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 08/27/2023
Certification Date: 08/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3690 S MAIN ST
SOUTH SALT LAKE UT
84115-4423
US

IV. Provider business mailing address

158 W THISTLE DR
SARATOGA SPRINGS UT
84045-6592
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-2525
  • Fax: 801-261-0503
Mailing address:
  • Phone: 775-544-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11989340-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: