Healthcare Provider Details

I. General information

NPI: 1275127490
Provider Name (Legal Business Name): CAMMI JO FRUIN AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2021
Last Update Date: 04/26/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 W 910 S STE 203
HEBER CITY UT
84032-2447
US

IV. Provider business mailing address

1144 N 455 W UNIT 6
MIDWAY UT
84049-6493
US

V. Phone/Fax

Practice location:
  • Phone: 801-712-0994
  • Fax: 888-807-7464
Mailing address:
  • Phone: 801-712-0994
  • Fax: 888-807-7464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number341638-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number341638-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: