MEDICARE: DR. SUE ELLEN FISHER PHD, APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0809X	Adult Psychiatric/Mental Health Registered Nurse	1947254405	UT
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	194725-4405	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	U006 107001404101	OTHER	UT	INTRMTN. HEALTH CARE
2	U002 262141	OTHER	UT	DESERET MUTUAL
3	U003 942938348F11	OTHER	UT	EDUCATORS MUTUAL
4	U009 942938348	OTHER	UT	CHAMPUS

General Provider Information

NPI Number	:	1568449619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUE ELLEN FISHER PHD, APRN

Provider Business Mailing Address
First Line	:	2994 TOLCATE LN
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-1529
Country	:	US
Telephone Number	:	801-278-4598
Fax Number	:

Provider Business Practice Location Address
First Line	:	2994 TOLCATE LN
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-1529
Country	:	US
Telephone Number	:	801-278-4598
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	03/07/2023

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