MEDICARE: EKAETE UDODONG APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	198596-4405	UT
2	363L00000X	Nurse Practitioner	198596-4405	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083676647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EKAETE UDODONG APRN

Provider Business Mailing Address
First Line	:	1055 N 500 W
Second Line	:	ATTN: CREDENTIALING
City	:	PROVO
State	:	UT
Zip	:	84604-3305
Country	:	US
Telephone Number	:	801-354-8225
Fax Number	:	801-418-0941

Provider Business Practice Location Address
First Line	:	1886 W 800 N
Second Line	:
City	:	PLEASANT GROVE
State	:	UT
Zip	:	84062-4097
Country	:	US
Telephone Number	:	801-756-5288
Fax Number	:	801-756-7589

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	11/27/2023

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Directions to “ EKAETE UDODONG APRN” Practice Location

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