Provider Demographics
NPI:1104374909
Name:NELSON, SALLY HART (IBCLC)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:HART
Last Name:NELSON
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:HN
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IBCLC
Mailing Address - Street 1:6480 S 2800 E
Mailing Address - Street 2:
Mailing Address - City:UINTAH
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5491
Mailing Address - Country:US
Mailing Address - Phone:801-621-4844
Mailing Address - Fax:
Practice Address - Street 1:150 S 600 E STE 2C
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2098
Practice Address - Country:US
Practice Address - Phone:435-764-2956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN