Provider Demographics
NPI:1124548789
Name:BROADHEAD, TAMARA LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:LYNN
Last Name:BROADHEAD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:LYNN
Other - Last Name:OLDROYD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10294 S ROYAL VISTA CV
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-3045
Mailing Address - Country:US
Mailing Address - Phone:817-319-9475
Mailing Address - Fax:
Practice Address - Street 1:10294 S ROYAL VISTA CV
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-3045
Practice Address - Country:US
Practice Address - Phone:817-319-9475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7096258-4405363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily