Individual
JUSTIN ALAN ILLUM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
971 E CREEKHILL LN APT 10, MIDVALE, UT 84047-2365
(417) 693-3850
Mailing address
971 E CREEKHILL LN APT 10, MIDVALE, UT 84047-2365
(417) 693-3850
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
10386297-4405
UT
390200000X
Student in an Organized Health Care Education/Training Program
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Other
Enumeration date
04/08/2022
Last updated
12/08/2024
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