Provider Demographics
NPI:1821222092
Name:CLYDE, LAURA (APRN)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:CLYDE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9071 S 1300 W
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-6672
Mailing Address - Country:US
Mailing Address - Phone:801-565-1162
Mailing Address - Fax:
Practice Address - Street 1:9071 S 1300 W
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-6672
Practice Address - Country:US
Practice Address - Phone:801-565-1162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-04
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7282627-3102390200000X
UT7282627-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program