Provider Demographics
NPI:1740944271
Name:ECCLES, LIANI (NP)
Entity type:Individual
Prefix:
First Name:LIANI
Middle Name:
Last Name:ECCLES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1638 N 200 W
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1900
Mailing Address - Country:US
Mailing Address - Phone:435-994-8693
Mailing Address - Fax:
Practice Address - Street 1:1034 RSI DR UNIT 120
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-2203
Practice Address - Country:US
Practice Address - Phone:435-512-7825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-30
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT7887916-4405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program