Healthcare Provider Details

I. General information

NPI: 1710830153
Provider Name (Legal Business Name): MARISA HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2026
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

853 S 325 W
OREM UT
84058-6786
US

IV. Provider business mailing address

853 S 325 W
OREM UT
84058-6786
US

V. Phone/Fax

Practice location:
  • Phone: 801-427-3376
  • Fax:
Mailing address:
  • Phone: 801-427-3376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8820747-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: