Provider Demographics
NPI:1972172260
Name:BRINGHURST, JACKIE (APRN)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:BRINGHURST
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:PO BOX 62
Mailing Address - Street 2:
Mailing Address - City:MONA
Mailing Address - State:UT
Mailing Address - Zip Code:84645-0062
Mailing Address - Country:US
Mailing Address - Phone:801-367-9585
Mailing Address - Fax:
Practice Address - Street 1:318 WEST 700 SOUTH
Practice Address - Street 2:#62
Practice Address - City:MONA
Practice Address - State:UT
Practice Address - Zip Code:84645-8464
Practice Address - Country:US
Practice Address - Phone:801-367-9585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT348575-3102163W00000X
UT348575-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse