Provider Demographics
NPI:1427235811
Name:ENNEN, REBECCA EMILY (FNP-BC)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:EMILY
Last Name:ENNEN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-649-7680
Mailing Address - Fax:
Practice Address - Street 1:750 ROUND VALLEY DR STE 201
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7549
Practice Address - Country:US
Practice Address - Phone:435-649-7680
Practice Address - Fax:435-776-9353
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP17730363LF0000X
UT11273913-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily