Healthcare Provider Details

I. General information

NPI: 1396342713
Provider Name (Legal Business Name): KATRINA POULSEN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 EAST RRIVERSIDE DR STE 301
ST. GEORGE UT
84790
US

IV. Provider business mailing address

617 E RIVERSIDE DR STE 301
ST GEORGE UT
84790-8722
US

V. Phone/Fax

Practice location:
  • Phone: 435-216-7000
  • Fax: 435-216-7001
Mailing address:
  • Phone: 435-216-7000
  • Fax: 435-216-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number70226834405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number835835
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: