Healthcare Provider Details

I. General information

NPI: 1003635004
Provider Name (Legal Business Name): EMMA FONG APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3802 S 700 E
SALT LAKE CITY UT
84106-1182
US

IV. Provider business mailing address

971 W TIFFANY DALE WAY
BLUFFDALE UT
84065-1836
US

V. Phone/Fax

Practice location:
  • Phone: 801-264-6000
  • Fax:
Mailing address:
  • Phone: 801-960-0620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number118761824405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number118761824405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: