Healthcare Provider Details

I. General information

NPI: 1336604610
Provider Name (Legal Business Name): SARA MARIE ELLIS SIMONSEN CNM, MSPH, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2019
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 ROUND VALLEY DR
PARK CITY UT
84060-7571
US

IV. Provider business mailing address

10 S 2000 E RM 410
SALT LAKE CITY UT
84112-5880
US

V. Phone/Fax

Practice location:
  • Phone: 435-333-1500
  • Fax:
Mailing address:
  • Phone: 801-585-9360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number5037536-4402
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: