Provider Demographics
NPI:1225395544
Name:WALTON, HEATHER LYNN (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
Last Name:WALTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LYNN
Other - Last Name:BRUNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:127 SOUTH 500 EAST #600
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1971
Mailing Address - Country:US
Mailing Address - Phone:801-587-6705
Mailing Address - Fax:801-715-8228
Practice Address - Street 1:2000 CIRCLE OF HOPE
Practice Address - Street 2:CLINIC 2E
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84112-5550
Practice Address - Country:US
Practice Address - Phone:801-587-4024
Practice Address - Fax:801-585-3846
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106253363A00000X
UT10528186-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant