Provider Demographics
NPI:1518597111
Name:SWENSON, SOPHIE MCKLANE
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:MCKLANE
Last Name:SWENSON
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 1:1726 BUCKLEY LN
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-5031
Mailing Address - Country:US
Mailing Address - Phone:801-373-6562
Mailing Address - Fax:
Practice Address - Street 1:1726 BUCKLEY LN
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-5031
Practice Address - Country:US
Practice Address - Phone:801-373-6562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker