Provider Demographics
NPI:1225512064
Name:BAUCOM, HEATHER (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BAUCOM
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 CIRCLE OF HOPE DR # 4146
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-5550
Mailing Address - Country:US
Mailing Address - Phone:801-803-4175
Mailing Address - Fax:
Practice Address - Street 1:2000 CIRCLE OF HOPE DR # 4146
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5550
Practice Address - Country:US
Practice Address - Phone:801-803-4175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKF07180626363LF0000X
UT8248067-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily