Provider Demographics
NPI:1467132621
Name:JUDD, VANESA NICOL CANNON
Entity Type:Individual
Prefix:
First Name:VANESA
Middle Name:NICOL CANNON
Last Name:JUDD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 E ALPINE TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-4507
Mailing Address - Country:US
Mailing Address - Phone:385-312-3828
Mailing Address - Fax:
Practice Address - Street 1:893 E 9400 S
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3671
Practice Address - Country:US
Practice Address - Phone:385-335-7862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT96056983102363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner