Healthcare Provider Details

I. General information

NPI: 1285168575
Provider Name (Legal Business Name): MARYJANE HYDE BOLDT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8TH AVE C STREET LDS HOSPITAL (W7)
SALT LAKE CITY UT
84103
US

IV. Provider business mailing address

2834 E 4510 S
SALT LAKE CITY UT
84117-4661
US

V. Phone/Fax

Practice location:
  • Phone: 801-408-2700
  • Fax: 801-408-5620
Mailing address:
  • Phone: 801-541-1432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6686503-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: