Healthcare Provider Details

I. General information

NPI: 1528734118
Provider Name (Legal Business Name): ADAM C ELLIS PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9069 S 1300 W
WEST JORDAN UT
84088-6713
US

IV. Provider business mailing address

9069 S 1300 W
WEST JORDAN UT
84088-6713
US

V. Phone/Fax

Practice location:
  • Phone: 801-483-1600
  • Fax:
Mailing address:
  • Phone: 801-483-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9405969-4408
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: