Basic Information
| Provider Information | |||||||||
| NPI: | 1881620714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | MINTZ | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 650 KOMAS DR | ||||||||
| Address2: | SUITE #200 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841081229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015850394 | ||||||||
| FaxNumber: | 8015818979 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 KOMAS DR | ||||||||
| Address2: | SUITE #200 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841081229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015850394 | ||||||||
| FaxNumber: | 8015818979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 10/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 205069-4405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.