MEDICARE: SONDRA DIANE HEASTON NP-C

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	363LF0000X	Family Nurse Practitioner	217181-4405	UT
2	363LF0000X	Family Nurse Practitioner	217181-8900	UT

General Provider Information

NPI Number	:	1104916956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SONDRA DIANE HEASTON NP-C

Provider Business Mailing Address
First Line	:	1481 N 1450 E
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-3714
Country	:	US
Telephone Number	:	801-377-1298
Fax Number	:

Provider Business Practice Location Address
First Line	:	3215 VALLEY ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-4217
Country	:	US
Telephone Number	:	801-466-3102
Fax Number	:

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	07/08/2007

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