Healthcare Provider Details

I. General information

NPI: 1245744010
Provider Name (Legal Business Name): SUSAN KAYE MADSEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN KAYE GARDNER RN

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 11/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4583 W WARM CANYON LN
SOUTH JORDAN UT
84009-5029
US

IV. Provider business mailing address

4583 W WARM CANYON LN
SOUTH JORDAN UT
84009-5029
US

V. Phone/Fax

Practice location:
  • Phone: 801-404-0059
  • Fax:
Mailing address:
  • Phone: 801-404-0059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number95024110
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: