=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942478540
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JANNA HARTLE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2008
-----------------------------------------------------
Last Update Date | 02/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1553 STONEMOOR CIR
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84121-2515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-274-1447
-----------------------------------------------------
Fax | 801-273-0775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1553 STONEMOOR CIR
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84121-2515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-274-1447
-----------------------------------------------------
Fax | 801-273-0775
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JANNA HARTLE
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 801-274-1447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 201619-4405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------