Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 4951373-4405 | UT |
NPI | 1003372806 |
---|---|
Provider Name | Amanda Borup |
First Address | Logan, UT 84321-4034 |
Second Address | Logan, UT 84321-4034 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/02/2019 |
Last Update Date | 07/03/2019 |