Healthcare Provider Details

I. General information

NPI: 1497176911
Provider Name (Legal Business Name): MARY-FAITH FULLER CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2013
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12176 S 1000 E STE G
DRAPER UT
84020-9734
US

IV. Provider business mailing address

12176 S 1000 E STE G
DRAPER UT
84020-9734
US

V. Phone/Fax

Practice location:
  • Phone: 801-523-3030
  • Fax: 801-523-3033
Mailing address:
  • Phone: 801-523-3030
  • Fax: 801-523-3033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number7737232-4405
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: