Healthcare Provider Details

I. General information

NPI: 1467606228
Provider Name (Legal Business Name): MARILYN LOUISE LITTLE APRN, PP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2008
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 W 7200 S
MIDVALE UT
84047-3749
US

IV. Provider business mailing address

198 W 7200 S
MIDVALE UT
84047-3749
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-4423
  • Fax:
Mailing address:
  • Phone: 801-566-4423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number21382844405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number2138288900
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: