Provider Demographics
NPI:1427297084
Name:DOUGLAS, WENDY S (ARNP)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:S
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:S
Other - Last Name:CHILD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1160 E 3900 S
Mailing Address - Street 2:SUITE 3500
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1202
Mailing Address - Country:US
Mailing Address - Phone:801-743-4750
Mailing Address - Fax:801-743-4765
Practice Address - Street 1:1160 E 3900 S
Practice Address - Street 2:SUITE 3500
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1202
Practice Address - Country:US
Practice Address - Phone:801-743-4750
Practice Address - Fax:801-743-4765
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT193897-4405363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000065564Medicare PIN
P00691513Medicare PIN