Healthcare Provider Details

I. General information

NPI: 1649864562
Provider Name (Legal Business Name): BELLANCA JEANINE WYERS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BELLANCA JEANINE PAYNE

II. Dates (important events)

Enumeration Date: 02/22/2021
Last Update Date: 10/22/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1792 W 1700 S
SYRACUSE UT
84075-9645
US

IV. Provider business mailing address

1792 W 1700 S
SYRACUSE UT
84075-9645
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-8644
  • Fax:
Mailing address:
  • Phone: 801-773-8644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12413980-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: