Provider Demographics
NPI:1871164426
Name:TEASDALE, MICHELLE LORRAINE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LORRAINE
Last Name:TEASDALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4393 N SHADY HOLLOW LOOP
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2343
Mailing Address - Country:US
Mailing Address - Phone:801-349-6249
Mailing Address - Fax:
Practice Address - Street 1:3415 S 900 W
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84119-4103
Practice Address - Country:US
Practice Address - Phone:385-468-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5906820-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily