Provider Demographics
NPI:1376569798
Name:HOLVERSON, RENA (APRN)
Entity Type:Individual
Prefix:
First Name:RENA
Middle Name:
Last Name:HOLVERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S 400 E
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4933
Mailing Address - Country:US
Mailing Address - Phone:801-408-1100
Mailing Address - Fax:
Practice Address - Street 1:400 C ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84143-1005
Practice Address - Country:US
Practice Address - Phone:801-408-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2022784405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000062187Medicare PIN