MEDICARE: CHELESE SOUTHWICK

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	163WX0200X	Oncology Registered Nurse	13975465-3102	UT

General Provider Information

NPI Number	:	1831026558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHELESE SOUTHWICK

Provider Business Mailing Address
First Line	:	1112 FAWN DR
Second Line	:
City	:	PLEASANT VIEW
State	:	UT
Zip	:	84414-1335
Country	:	US
Telephone Number	:	801-628-5475
Fax Number	:

Provider Business Practice Location Address
First Line	:	1112 FAWN DR
Second Line	:
City	:	PLEASANT VIEW
State	:	UT
Zip	:	84414-1335
Country	:	US
Telephone Number	:	801-628-5475
Fax Number	:

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

Provider Enumeration Date	:	05/06/2026
Last Update Date	:	05/06/2026

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Directions to “ CHELESE SOUTHWICK ” Practice Location

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