Provider Demographics
NPI:1053776807
Name:MORTENSEN, SYDNEY DAWN
Entity type:Individual
Prefix:MISS
First Name:SYDNEY
Middle Name:DAWN
Last Name:MORTENSEN
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 1:2958 E SOMERSET DR
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-5050
Mailing Address - Country:US
Mailing Address - Phone:801-885-6246
Mailing Address - Fax:
Practice Address - Street 1:2958 E SOMERSET DR
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-5050
Practice Address - Country:US
Practice Address - Phone:801-885-6246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT178482586390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program