Healthcare Provider Details

I. General information

NPI: 1255927612
Provider Name (Legal Business Name): KRYSTLE DAWN LOWRANCE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2020
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 E 2000 N STE 110
TOOELE UT
84074-9335
US

IV. Provider business mailing address

654 W 770 N
TOOELE UT
84074-3730
US

V. Phone/Fax

Practice location:
  • Phone: 435-843-3677
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10399744-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number103997444405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: