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General NPI Number Information
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NPI Number | 1770437824
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Entity Type | Individual
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Provider Name | AUDRA RYSEVAS
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Gender | Female
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Dates
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Enumeration Date | 02/25/2026
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Last Update Date | 02/25/2026
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Provider Practice Location Address
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Address Line | 140 W 2100 S STE 130B
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City | SALT LAKE CITY
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State | UT
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Zip | 84115-1854
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Country | US
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Telephone | 801-896-7930
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Fax |
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Provider Business Mailing Address
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Address Line | 140 W 2100 S STE 130B
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City | SOUTH SALT LAKE
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State | UT
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Zip | 84115-1854
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Country | US
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Telephone | 801-896-1930
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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 | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | F25-117395
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License Number State | UT
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