Provider Demographics
NPI:1073243531
Name:BERMINGHAM, MEKENNA ANDREE (APRN)
Entity Type:Individual
Prefix:
First Name:MEKENNA
Middle Name:ANDREE
Last Name:BERMINGHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1382 N 985 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2466
Mailing Address - Country:US
Mailing Address - Phone:801-598-2285
Mailing Address - Fax:
Practice Address - Street 1:3723 W 12600 S STE 330
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7309
Practice Address - Country:US
Practice Address - Phone:801-285-4543
Practice Address - Fax:801-285-4540
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8497877-4405363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics