Provider Demographics
NPI:1285326041
Name:PRINCE, NATHANAEL JAY
Entity type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:JAY
Last Name:PRINCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 N 1075 W STE 220
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2745
Mailing Address - Country:US
Mailing Address - Phone:801-897-8711
Mailing Address - Fax:385-333-7202
Practice Address - Street 1:1401 N 1075 W STE 220
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2745
Practice Address - Country:US
Practice Address - Phone:801-897-8711
Practice Address - Fax:385-333-7202
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist