Healthcare Provider Details

I. General information

NPI: 1689078008
Provider Name (Legal Business Name): CHARLEE K OLLERTON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHARLEE K DALTON FNP

II. Dates (important events)

Enumeration Date: 10/14/2014
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 HARRISON BLVD
SOUTH OGDEN UT
84403-3195
US

IV. Provider business mailing address

4401 HARRISON BLVD
SOUTH OGDEN UT
84403-3195
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-5518
  • Fax:
Mailing address:
  • Phone: 801-387-5518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number309515-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number309515-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: