Provider Demographics
NPI:1841844057
Name:VENCES, MAYRA IBETH (NP-C)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:IBETH
Last Name:VENCES
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1146 N ANTILLES DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4656
Mailing Address - Country:US
Mailing Address - Phone:801-673-8082
Mailing Address - Fax:
Practice Address - Street 1:1146 N ANTILLES DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-4656
Practice Address - Country:US
Practice Address - Phone:801-673-8082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT82272178-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily