MEDICARE: HEATHER BAUCOM APRN, CNP

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	F07180626	OK
2	363LF0000X	Family Nurse Practitioner	8248067-4405	UT

General Provider Information

NPI Number	:	1225512064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER BAUCOM APRN, CNP

Provider Business Mailing Address
First Line	:	2000 CIRCLE OF HOPE DR # 4146
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84112-5550
Country	:	US
Telephone Number	:	801-803-4175
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 CIRCLE OF HOPE DR # 4146
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84112-5550
Country	:	US
Telephone Number	:	801-803-4175
Fax Number	:

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

Provider Enumeration Date	:	09/18/2018
Last Update Date	:	10/21/2021

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