Healthcare Provider Details

I. General information

NPI: 1295954097
Provider Name (Legal Business Name): MARTHA L BRAY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 SHEPARD LN
FARMINGTON UT
84025-3934
US

IV. Provider business mailing address

630 SHEPARD LN
FARMINGTON UT
84025-3934
US

V. Phone/Fax

Practice location:
  • Phone: 801-447-8680
  • Fax: 801-447-4211
Mailing address:
  • Phone: 801-447-8680
  • Fax: 801-447-4211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN1003X
TaxonomyNutrition Support Registered Nurse
License Number160926-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: