Provider Demographics
NPI:1801866512
Name:VAN WAGONER, KIMBER TRACY (BA, RN)
Entity Type:Individual
Prefix:MS
First Name:KIMBER
Middle Name:TRACY
Last Name:VAN WAGONER
Suffix:
Gender:F
Credentials:BA, RN
Other - Prefix:MS
Other - First Name:KYMBER
Other - Middle Name:TRACY
Other - Last Name:VAN WAGONER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA, RN
Mailing Address - Street 1:1134 E 2700 S
Mailing Address - Street 2:D 26
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2642
Mailing Address - Country:US
Mailing Address - Phone:801-486-4104
Mailing Address - Fax:
Practice Address - Street 1:1020 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-3176
Practice Address - Country:US
Practice Address - Phone:801-539-7000
Practice Address - Fax:801-539-7050
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT03081433102163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTNPP000Medicare UPIN