Provider Demographics
NPI:1497526990
Name:PRINCE, DESIREE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:PRINCE
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 1:575 W 7950 S
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:UT
Mailing Address - Zip Code:84340-6709
Mailing Address - Country:US
Mailing Address - Phone:801-648-0065
Mailing Address - Fax:
Practice Address - Street 1:575 W 7950 S
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:UT
Practice Address - Zip Code:84340-6709
Practice Address - Country:US
Practice Address - Phone:801-648-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker