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General NPI Number Information
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NPI Number | 1275469660
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Entity Type | Individual
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Provider Name | JEWELIANNA RAE WILLDEN PTA
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Gender | Female
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Dates
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Enumeration Date | 06/22/2026
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Last Update Date | 06/22/2026
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Provider Practice Location Address
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Address Line | 655 E 400 S STE D
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City | SPRINGVILLE
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State | UT
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Zip | 84663-2039
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Country | US
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Telephone | 385-398-1915
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Fax |
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Provider Business Mailing Address
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Address Line | 1200 E 520 S
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City | PROVO
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State | UT
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Zip | 84606-5338
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 142015022402
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License Number State | UT
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