Provider Demographics
NPI:1649398694
Name:WITHERS, INEZ B (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:INEZ
Middle Name:B
Last Name:WITHERS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27
Mailing Address - Street 2:
Mailing Address - City:MORGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84050-0027
Mailing Address - Country:US
Mailing Address - Phone:256-425-7884
Mailing Address - Fax:
Practice Address - Street 1:157 N COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:MORGAN
Practice Address - State:UT
Practice Address - Zip Code:84050-9570
Practice Address - Country:US
Practice Address - Phone:256-425-7884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-095255163WC0400X
UT106663828900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Single Specialty