Provider Demographics
NPI:1396499414
Name:WASATCH FUNCTIONAL MEDICINE
Entity type:Organization
Organization Name:WASATCH FUNCTIONAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:801-332-9034
Mailing Address - Street 1:5711 S 1475 E STE 201
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5185
Mailing Address - Country:US
Mailing Address - Phone:801-332-9034
Mailing Address - Fax:
Practice Address - Street 1:5711 S 1475 E STE 201
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5185
Practice Address - Country:US
Practice Address - Phone:801-332-9034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty