Healthcare Provider Details

I. General information

NPI: 1689298085
Provider Name (Legal Business Name): SARA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 S REDWOOD RD
WEST JORDAN UT
84084-5518
US

IV. Provider business mailing address

1035 E MANSFIELD AVE
SALT LAKE CITY UT
84106-2123
US

V. Phone/Fax

Practice location:
  • Phone: 801-966-1118
  • Fax:
Mailing address:
  • Phone: 801-734-0421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8546685-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8546685-4405
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number8546685-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: