1609433572 NPI number — DR. JENNYLYNN F PALISOC ARNP

Table of content: DR. JENNYLYNN F PALISOC ARNP (NPI 1609433572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609433572 NPI number — DR. JENNYLYNN F PALISOC ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PALISOC
Provider First Name:
JENNYLYNN
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1609433572
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
07/22/2019
NPI Reactivation Date:
07/29/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 FOOTHILL DRIVE
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:
84148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-582-1565
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 FOOTHILL DRIVE
Provider Second Line Business Practice Location Address:
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:
84148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-582-1565
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2019

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: 390200000X , with the licence number:  AP60962323 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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