MEDICARE: CHARLES L HEAD 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	363LF0000X	Family Nurse Practitioner	9266563-4405	UT

General Provider Information

NPI Number	:	1295423283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES L HEAD APRN

Provider Business Mailing Address
First Line	:	3838 S 700 E STE 300
Second Line	:
City	:	SOUTH SALT LAKE
State	:	UT
Zip	:	84106-1496
Country	:	US
Telephone Number	:	801-261-4988
Fax Number	:

Provider Business Practice Location Address
First Line	:	3838 S 700 E STE 300
Second Line	:
City	:	SOUTH SALT LAKE
State	:	UT
Zip	:	84106-1496
Country	:	US
Telephone Number	:	801-261-4988
Fax Number	:

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

Provider Enumeration Date	:	04/27/2023
Last Update Date	:	03/21/2024

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Directions to “ CHARLES L HEAD APRN” Practice Location

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