Provider Demographics
NPI:1720445307
Name:INTERMOUNTAIN HEALTHCARE
Entity Type:Organization
Organization Name:INTERMOUNTAIN HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:435-313-6330
Mailing Address - Street 1:884 BLACK ROCK DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:UT
Mailing Address - Zip Code:84765-5440
Mailing Address - Country:US
Mailing Address - Phone:435-313-6330
Mailing Address - Fax:
Practice Address - Street 1:884 BLACK ROCK DR
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:UT
Practice Address - Zip Code:84765-5440
Practice Address - Country:US
Practice Address - Phone:435-313-6330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6078476-4405282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital