Healthcare Provider Details

I. General information

NPI: 1144404385
Provider Name (Legal Business Name): MARY ANN EVANS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 N WYMOUNT TERRACE DR
PROVO UT
84602-4800
US

IV. Provider business mailing address

1750 N WYMOUNT TERRACE DR
PROVO UT
84602-4800
US

V. Phone/Fax

Practice location:
  • Phone: 801-422-2771
  • Fax: 801-422-0761
Mailing address:
  • Phone: 801-422-2771
  • Fax: 801-422-0761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number216177-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: