Provider Demographics
NPI:1285430207
Name:NORTHERN VALLEY FAMILY MEDICINE
Entity type:Organization
Organization Name:NORTHERN VALLEY FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:TAGG
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:801-557-5024
Mailing Address - Street 1:415 W 3400 S
Mailing Address - Street 2:
Mailing Address - City:NIBLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6461
Mailing Address - Country:US
Mailing Address - Phone:801-557-5024
Mailing Address - Fax:
Practice Address - Street 1:1415 N 400 E STE A
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7539
Practice Address - Country:US
Practice Address - Phone:435-753-2840
Practice Address - Fax:435-787-9422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty