Healthcare Provider Details

I. General information

NPI: 1174882856
Provider Name (Legal Business Name): MARILYN ROSS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 WRIGHT BROTHERS DR. MARILYN ROSS BLD #2
SALT LAKE CITY UT
84116
US

IV. Provider business mailing address

384 WRIGHT BROTHERS DR. ATTN: MARILYN ROSS BLD 2 MEDICAL CLINIC
SALT LAKE CITY UT
84116
US

V. Phone/Fax

Practice location:
  • Phone: 801-536-4910
  • Fax: 801-517-6453
Mailing address:
  • Phone: 801-536-4910
  • Fax: 801-517-6453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number203654-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number203654-8900
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: