Healthcare Provider Details

I. General information

NPI: 1104398361
Provider Name (Legal Business Name): LISA ANN OSTRANDER AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1385 W 2200 S
TAYLORSVILLE UT
84119-7205
US

IV. Provider business mailing address

1385 W 2200 S
TAYLORSVILLE UT
84119-7205
US

V. Phone/Fax

Practice location:
  • Phone: 801-944-0095
  • Fax:
Mailing address:
  • Phone: 801-944-0095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number7010732-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: