Healthcare Provider Details

I. General information

NPI: 1295403053
Provider Name (Legal Business Name): BRANDON CHRISTOPHER SPELLEN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2021
Last Update Date: 09/05/2021
Certification Date: 09/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3646 W GOLDEN SKY LN
SOUTH JORDAN UT
84009-3143
US

IV. Provider business mailing address

3646 W GOLDEN SKY LN
SOUTH JORDAN UT
84009-3143
US

V. Phone/Fax

Practice location:
  • Phone: 617-895-6542
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number10493809-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: