Healthcare Provider Details

I. General information

NPI: 1760968804
Provider Name (Legal Business Name): AMANDA GRAVES CANNON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 E 500 N STE 200
VINEYARD UT
84059-6004
US

IV. Provider business mailing address

667 E 500 N STE 200
VINEYARD UT
84059-6004
US

V. Phone/Fax

Practice location:
  • Phone: 801-669-5758
  • Fax: 801-216-8357
Mailing address:
  • Phone: 801-669-5758
  • Fax: 801-216-8357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number911041
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9111041-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: