Basic Information
| Provider Information | |||||||||
| NPI: | 1629414826 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAYABYAB | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WUERSTLIN | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 30180 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841300180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232801377 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5848 S FASHION BLVD | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841076157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013144100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2013 | ||||||||
| LastUpdateDate: | 10/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN17620 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 9750862-4405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.