Provider Demographics
NPI:1437874401
Name:BASCOM, ALLI (APRN)
Entity type:Individual
Prefix:MRS
First Name:ALLI
Middle Name:
Last Name:BASCOM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 S 1200 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5150
Mailing Address - Country:US
Mailing Address - Phone:801-358-2149
Mailing Address - Fax:
Practice Address - Street 1:3585 N UNIVERSITY AVE STE 250
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6622
Practice Address - Country:US
Practice Address - Phone:801-459-7147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8536735-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily