Provider Demographics
NPI:1629752043
Name:BOTHEM, ANNABELLE
Entity Type:Individual
Prefix:
First Name:ANNABELLE
Middle Name:
Last Name:BOTHEM
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 1:1062 W STONEHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-5032
Mailing Address - Country:US
Mailing Address - Phone:256-473-4997
Mailing Address - Fax:
Practice Address - Street 1:697 W 4170 S
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-1326
Practice Address - Country:US
Practice Address - Phone:801-261-9177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker