MEDICARE: PETER JOSEPH CLANCY

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	11560202-8900	UT

General Provider Information

NPI Number	:	1760337885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER JOSEPH CLANCY

Provider Business Mailing Address
First Line	:	73 E 200 N APT 304
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84606-6671
Country	:	US
Telephone Number	:	469-264-4639
Fax Number	:

Provider Business Practice Location Address
First Line	:	73 E 200 N APT 304
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84606-6671
Country	:	US
Telephone Number	:	469-264-4639
Fax Number	:

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

Provider Enumeration Date	:	03/03/2026
Last Update Date	:	03/09/2026

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