Provider Demographics
NPI:1720748874
Name:SUNRISE WOMENS HEALTH AND WELLNESS PLLC
Entity Type:Organization
Organization Name:SUNRISE WOMENS HEALTH AND WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKERING
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:385-448-0055
Mailing Address - Street 1:724 S 1600 W STE 200
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:UT
Mailing Address - Zip Code:84664-4349
Mailing Address - Country:US
Mailing Address - Phone:385-448-0055
Mailing Address - Fax:801-797-0281
Practice Address - Street 1:724 S 1600 W STE 200
Practice Address - Street 2:
Practice Address - City:MAPLETON
Practice Address - State:UT
Practice Address - Zip Code:84664-4349
Practice Address - Country:US
Practice Address - Phone:385-448-0055
Practice Address - Fax:801-797-0281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-29
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1720497597OtherNPPES