1497164180 NPI number — GITANJALI SHARMA ACNP-BC

Table of content: GITANJALI SHARMA ACNP-BC (NPI 1497164180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497164180 NPI number — GITANJALI SHARMA ACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHARMA
Provider First Name:
GITANJALI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ACNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497164180
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3668 S GILROY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84109-3825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-673-5156
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3920 S 1100 E
Provider Second Line Business Practice Location Address:
STE 250
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84124-1213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-308-8400
Provider Business Practice Location Address Fax Number:
801-349-2849
Provider Enumeration Date:
08/06/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  5660172-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1497164180 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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