Provider Demographics
NPI:1023696341
Name:WHITE, BREMOND (FNP-BC)
Entity type:Individual
Prefix:
First Name:BREMOND
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4151 N TRAVERSE MTN BLVD # 19-001
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2616
Mailing Address - Country:US
Mailing Address - Phone:801-440-0260
Mailing Address - Fax:
Practice Address - Street 1:4151 N TRAVERSE MTN BLVD # 19-001
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2616
Practice Address - Country:US
Practice Address - Phone:801-440-0260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT381082-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner