Healthcare Provider Details

I. General information

NPI: 1104580356
Provider Name (Legal Business Name): ELIZABETH MARIA DURHAM NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 E 10TH AVE STE 100
SALT LAKE CITY UT
84103-2870
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-408-7500
  • Fax:
Mailing address:
  • Phone: 801-408-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7081449-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: