Provider Demographics
NPI:1699514422
Name:WIGHTMAN, DESIRI (CPM, RD)
Entity type:Individual
Prefix:MRS
First Name:DESIRI
Middle Name:
Last Name:WIGHTMAN
Suffix:
Gender:F
Credentials:CPM, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6475 W 13100 S
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-8911
Mailing Address - Country:US
Mailing Address - Phone:385-343-2185
Mailing Address - Fax:
Practice Address - Street 1:1517 W GUN SMOKE DR
Practice Address - Street 2:
Practice Address - City:BLUFFDALE
Practice Address - State:UT
Practice Address - Zip Code:84065-5187
Practice Address - Country:US
Practice Address - Phone:900-343-3413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife