Basic Information
| Provider Information | |||||||||
| NPI: | 1235639709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIMBERLAKE | ||||||||
| FirstName: | MEAGHAN | ||||||||
| MiddleName: | NICOL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, MSN, FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOCH | ||||||||
| OtherFirstName: | MEAGHAN | ||||||||
| OtherMiddleName: | NICHOL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN, MSN, FNP-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1620 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPANISH FORK | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846601008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8018222234 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 602 31ST ST | ||||||||
| Address2: | |||||||||
| City: | HONDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788613512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102020250 | ||||||||
| FaxNumber: | 8303312287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2018 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP136326 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.