Healthcare Provider Details

I. General information

NPI: 1568075604
Provider Name (Legal Business Name): MICHELLE L DAVIS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 S 1100 E STE 305
SALT LAKE CITY UT
84102-4500
US

IV. Provider business mailing address

24 S 1100 E STE 305
SALT LAKE CITY UT
84102-4500
US

V. Phone/Fax

Practice location:
  • Phone: 385-290-1289
  • Fax: 385-290-1290
Mailing address:
  • Phone: 385-290-1289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7760277-4409
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: