Healthcare Provider Details

I. General information

NPI: 1750434981
Provider Name (Legal Business Name): MARISSA ANN HEWITT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 MEDICAL DR
BOUNTIFUL UT
84010-4908
US

IV. Provider business mailing address

1586 E MILLBROOK WAY
BOUNTIFUL UT
84010-1530
US

V. Phone/Fax

Practice location:
  • Phone: 801-299-2276
  • Fax:
Mailing address:
  • Phone: 801-298-3220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number309002-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: