Provider Demographics
NPI:1467986547
Name:WAITE, MEGAN MARIE
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:MARIE
Last Name:WAITE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MEGAN
Other - Middle Name:MARIE
Other - Last Name:BRANDT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:125 N MILL RD UNIT E404
Mailing Address - Street 2:
Mailing Address - City:VINEYARD
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5622
Mailing Address - Country:US
Mailing Address - Phone:503-410-8335
Mailing Address - Fax:
Practice Address - Street 1:750 N FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1677
Practice Address - Country:US
Practice Address - Phone:801-373-4760
Practice Address - Fax:801-373-0639
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2747980171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator