Provider Demographics
NPI:1154649077
Name:GRANTSVILLE HEALTH & WELLNESS CLINIC PC
Entity type:Organization
Organization Name:GRANTSVILLE HEALTH & WELLNESS CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:E
Authorized Official - Last Name:DEVRIES
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:435-843-9964
Mailing Address - Street 1:271 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-3116
Mailing Address - Country:US
Mailing Address - Phone:435-843-9964
Mailing Address - Fax:435-843-9964
Practice Address - Street 1:225 W APPLE ST
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84029-9635
Practice Address - Country:US
Practice Address - Phone:435-843-9964
Practice Address - Fax:435-843-9964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-17
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT288698-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty