Provider Demographics
NPI:1104622158
Name:HADDOCK, BRYNNA (FNP-C)
Entity type:Individual
Prefix:
First Name:BRYNNA
Middle Name:
Last Name:HADDOCK
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:BRYNNA
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W STE 222
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-354-8225
Practice Address - Fax:801-418-0941
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14205405-4405207Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine