Healthcare Provider Details

I. General information

NPI: 1679174346
Provider Name (Legal Business Name): MISS CORDALYNN FELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CASEY FELL

II. Dates (important events)

Enumeration Date: 11/07/2020
Last Update Date: 11/07/2020
Certification Date: 11/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4431 S HONEYWOOD LN
WEST VALLEY CITY UT
84120-5845
US

IV. Provider business mailing address

4431 S HONEYWOOD LN
WEST VALLEY CITY UT
84120-5845
US

V. Phone/Fax

Practice location:
  • Phone: 530-718-9304
  • Fax:
Mailing address:
  • Phone: 530-718-9304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: