Basic Information
| Provider Information | |||||||||
| NPI: | 1326239476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BATEMAN | ||||||||
| FirstName: | MIRIAM | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 N MAIN ST | ||||||||
| Address2: | COMMUNITY HEALTH | ||||||||
| City: | TOOELE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840742141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358432310 | ||||||||
| FaxNumber: | 4358432304 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 N MAIN ST | ||||||||
| Address2: | COMMUNITY HEALTH | ||||||||
| City: | TOOELE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840742141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358432310 | ||||||||
| FaxNumber: | 4358432304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 08/05/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | 203457-3102 | UT | Y | Nursing Service Providers | Registered Nurse | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 998877663001 | 05 | UT | MEDICAID |