Basic Information
| Provider Information | |||||||||
| NPI: | 1497212120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTLEY | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 198560 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303848560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017717717 | ||||||||
| FaxNumber: | 8665061474 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SNOW CREEK DR | ||||||||
| Address2: | |||||||||
| City: | PARK CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840607372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356550055 | ||||||||
| FaxNumber: | 4356558979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2019 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 7544993-4405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1578859831 | 05 | UT | MEDICAID |