Healthcare Provider Details

I. General information

NPI: 1285018408
Provider Name (Legal Business Name): MARY CAROLYN FLECK APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 W 2100 S
SALT LAKE CITY UT
84119-1401
US

IV. Provider business mailing address

127 S. 500 E SUITE 600
SALT LAKE CITY UT
84102-1971
US

V. Phone/Fax

Practice location:
  • Phone: 801-213-8841
  • Fax:
Mailing address:
  • Phone: 801-587-6336
  • Fax: 801-715-8228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7339847-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: