Healthcare Provider Details

I. General information

NPI: 1689008773
Provider Name (Legal Business Name): ASHLEY VALLEY PHYSICIAN PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 W HIGHWAY 40 STE 202
VERNAL UT
84078
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY
BRENTWOOD TN
37027-5098
US

V. Phone/Fax

Practice location:
  • Phone: 435-781-3053
  • Fax: 435-781-3055
Mailing address:
  • Phone: 615-920-7000
  • Fax: 615-920-8775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHARLOTTE LAWRENCE
Title or Position: SECRETARY
Credential:
Phone: 615-920-7000