Basic Information
| Provider Information | |||||||||
| NPI: | 1225395544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTON | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRUNELL | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 127 SOUTH 500 EAST #600 | ||||||||
| Address2: | |||||||||
| City: | SLC | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015876705 | ||||||||
| FaxNumber: | 8017158228 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 CIRCLE OF HOPE | ||||||||
| Address2: | CLINIC 2E | ||||||||
| City: | SLC | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841125550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015874024 | ||||||||
| FaxNumber: | 8015853846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2012 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9106253 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 10528186-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.