Provider Demographics
NPI:1922246487
Name:HEPBURN, JEANETTE C (APRN)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:C
Last Name:HEPBURN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:C
Other - Last Name:SMILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:286 N GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9733
Mailing Address - Country:US
Mailing Address - Phone:435-755-9174
Mailing Address - Fax:435-755-9148
Practice Address - Street 1:286 N GATEWAY DR
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9733
Practice Address - Country:US
Practice Address - Phone:435-755-9174
Practice Address - Fax:435-755-9148
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT0329116-1204363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5945Medicaid
UT005769202Medicare PIN