Healthcare Provider Details

I. General information

NPI: 1376545251
Provider Name (Legal Business Name): PHYLLIS A ASELTINE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3702 S STATE ST STE 107
SOUTH SALT LAKE UT
84115-5096
US

IV. Provider business mailing address

3702 S STATE ST STE 107
SOUTH SALT LAKE UT
84115-5096
US

V. Phone/Fax

Practice location:
  • Phone: 801-288-2634
  • Fax: 801-288-1186
Mailing address:
  • Phone: 801-288-2634
  • Fax: 801-288-1186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1835254405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1835254405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: