Provider Demographics
NPI:1528561693
Name:HARTLEY, GEORGIA RUSSELLYN (LICENSED ACUPUNCTURI)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:RUSSELLYN
Last Name:HARTLEY
Suffix:
Gender:F
Credentials:LICENSED ACUPUNCTURI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4287 HARRISON BLVD # 156
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3101
Mailing Address - Country:US
Mailing Address - Phone:801-540-3502
Mailing Address - Fax:
Practice Address - Street 1:2245 MONROE BLVD APT 29
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-1743
Practice Address - Country:US
Practice Address - Phone:801-540-3502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1690016-1201171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist