Healthcare Provider Details

I. General information

NPI: 1578195905
Provider Name (Legal Business Name): HAZEL MARIANO FNP, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date: 07/16/2020
Reactivation Date: 07/24/2026

III. Provider practice location address

1638 N 200 W
LOGAN UT
84341-1900
US

IV. Provider business mailing address

1638 N 200 W
LOGAN UT
84341-1900
US

V. Phone/Fax

Practice location:
  • Phone: 805-297-0487
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13115305-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: