Healthcare Provider Details

I. General information

NPI: 1316370901
Provider Name (Legal Business Name): EMILY ANN BULLOCK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2013
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 S COTTONWOOD ST BUILDING 4 LL1
MURRAY UT
84107-5701
US

IV. Provider business mailing address

5121 S COTTONWOOD ST BUILDING 4 LL1
MURRAY UT
84107-5701
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-4000
  • Fax: 801-507-4811
Mailing address:
  • Phone: 801-507-4000
  • Fax: 801-507-4811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number208547-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: