Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife |
NPI | 1033372081 |
---|---|
Provider Name | Mrs. Angie Rena Blackett |
First Address | Saratoga Springs, UT 84045-6408 |
Second Address | West Jordan, UT 84084-5610 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/07/2008 |
Last Update Date | 07/05/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
08100017 | NORTH AMERICAN REGISTRY OF MIDWIVES (01) | |
286486-3400 | STATE LICENSE (01) | UT |