MEDICARE: MAYRA IBETH VENCES 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	82272178-4405	UT

General Provider Information

NPI Number	:	1841844057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYRA IBETH VENCES NP-C

Provider Business Mailing Address
First Line	:	1146 N ANTILLES DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116-4656
Country	:	US
Telephone Number	:	801-673-8082
Fax Number	:

Provider Business Practice Location Address
First Line	:	1146 N ANTILLES DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116-4656
Country	:	US
Telephone Number	:	801-673-8082
Fax Number	:

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

Provider Enumeration Date	:	07/25/2019
Last Update Date	:	07/25/2019

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