Provider Demographics
NPI:1376545251
Name:ASELTINE, PHYLLIS A (FNP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:A
Last Name:ASELTINE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 E 4500 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2900
Mailing Address - Country:US
Mailing Address - Phone:801-288-2634
Mailing Address - Fax:801-288-1186
Practice Address - Street 1:650 E 4500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2900
Practice Address - Country:US
Practice Address - Phone:801-288-2634
Practice Address - Fax:801-288-1186
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1835254405363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
005537606Medicare ID - Type Unspecified
Q22384Medicare UPIN