Provider Demographics
NPI:1669217774
Name:MORTENSEN, CASEY (RD, IBCLC)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:RD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4765 N GRANDVIEW PEAK DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-5440
Mailing Address - Country:US
Mailing Address - Phone:480-393-9933
Mailing Address - Fax:
Practice Address - Street 1:4765 N GRANDVIEW PEAK DR
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-5440
Practice Address - Country:US
Practice Address - Phone:480-393-9933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-315224174N00000X
1090229133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN