Provider Demographics
NPI:1063067346
Name:VAN RENSBURG, SAMUEL HARRY (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:HARRY
Last Name:VAN RENSBURG
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5770 S 1500 W BLDG G
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5216
Mailing Address - Country:US
Mailing Address - Phone:801-313-7770
Mailing Address - Fax:
Practice Address - Street 1:5770 S 1500 W
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-5216
Practice Address - Country:US
Practice Address - Phone:203-343-9490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN02110363LG0600X, 363LP2300X
UT11839389-4405363LP0808X
UT11839389-4409363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care