Healthcare Provider Details

I. General information

NPI: 1942274428
Provider Name (Legal Business Name): MARY MARTHA ATIEE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N MAIN ST SUITE 117
LOGAN UT
84321-3983
US

IV. Provider business mailing address

919 MILESTONE DR
SMITHFIELD UT
84335-2552
US

V. Phone/Fax

Practice location:
  • Phone: 435-753-0724
  • Fax:
Mailing address:
  • Phone: 435-563-0365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number5658728-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: