Bonnie Leigh Wallace, FNP-C

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

7682759-4405 Issued in UT

Practice address

12573 S Liberty Hill CT
Herriman, UT 84096-7774

Phone

(801) 690-4899

NPI assigned

Nov 4, 2024

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in UT

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

Other, 2024

Medicare assignment

May accept Medicare assignment

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: bwallace746194@direct.med.utah.edu

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Utah Cancer Specialists PC

  • Medical Oncology Physician
  • Salt Lake City, UT
  • NPI 1619925369
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1730678400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1730678400000",
    "number": "1871316372",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12573 S LIBERTY HILL CT",
            "city": "HERRIMAN",
            "state": "UT",
            "postal_code": "840967774",
            "telephone_number": "801-690-4899"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12573 S LIBERTY HILL CT",
            "city": "HERRIMAN",
            "state": "UT",
            "postal_code": "840967774",
            "telephone_number": "801-690-4899"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "BONNIE",
        "middle_name": "LEIGH",
        "credential": "FNP-C",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2024-11-04",
        "last_updated": "2024-11-04",
        "certification_date": "2024-10-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "UT",
            "license": "7682759-4405",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Karly Vovk
• Thomas Henry Wadleigh, CMHC, LMHC
• Tarah Michelle Waite
• Walgreen Co.
• Erin Walker
• Walmart Inc.
• Kelsey Walter
• Chelsea Ware
• Wasatch Rehab Inc
• Lora J Watkins, LCSW

• Family Nurse Practitioner in Herriman, UT
• Providers in Herriman, UT by specialty
• Family Nurse Practitioner in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 4, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.