Provider Demographics
NPI:1770070260
Name:EASTERN UTAH WOMENS HEALTH LLC
Entity type:Organization
Organization Name:EASTERN UTAH WOMENS HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENDERGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, WHNP-BC
Authorized Official - Phone:435-637-0313
Mailing Address - Street 1:PO BOX 656
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-0656
Mailing Address - Country:US
Mailing Address - Phone:435-637-0313
Mailing Address - Fax:435-637-0317
Practice Address - Street 1:77 S 600 E STE B
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-3174
Practice Address - Country:US
Practice Address - Phone:435-637-0313
Practice Address - Fax:435-637-0317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3196374405363LW0102X
363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1225257819Medicaid