Healthcare Provider Details

I. General information

NPI: 1215902309
Provider Name (Legal Business Name): MARSHA K MEDFORD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 E 300 N WASATCH MENTAL HEALTH, YOUTH OUTPATIENT
PROVO UT
84606-3539
US

IV. Provider business mailing address

259 S 500 E
PROVO UT
84606-4731
US

V. Phone/Fax

Practice location:
  • Phone: 801-377-1213
  • Fax: 801-356-2703
Mailing address:
  • Phone: 801-377-1213
  • Fax: 801-356-2703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5376965-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: