Provider Demographics
NPI:1932353380
Name:SOUTHERLAND, ANDREA GRAHAM (NP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:GRAHAM
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 W 12600 S STE 102
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7080
Mailing Address - Country:US
Mailing Address - Phone:801-254-4600
Mailing Address - Fax:801-254-9670
Practice Address - Street 1:1420 W 12600 S STE 102
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7080
Practice Address - Country:US
Practice Address - Phone:801-254-4600
Practice Address - Fax:801-254-9670
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4552609-4405363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1932353380OtherNPI