Healthcare Provider Details

I. General information

NPI: 1386216539
Provider Name (Legal Business Name): ROBERT SCOTT FLETCHER FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5373 W LAKE PARK BLVD
WEST VALLEY UT
84120-8208
US

IV. Provider business mailing address

5373 W LAKE PARK BLVD
WEST VALLEY CITY UT
84120-8208
US

V. Phone/Fax

Practice location:
  • Phone: 801-902-8080
  • Fax:
Mailing address:
  • Phone: 801-902-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8191555-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number81915553102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: