Healthcare Provider Details

I. General information

NPI: 1568685550
Provider Name (Legal Business Name): MARTHA FERN SOUTHWICK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6575 S REDWOOD RD STE 240
SALT LAKE CITY UT
84123-5694
US

IV. Provider business mailing address

1947 KATE CV
WEST JORDAN UT
84088-6631
US

V. Phone/Fax

Practice location:
  • Phone: 801-432-7712
  • Fax:
Mailing address:
  • Phone: 801-561-2280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2000204405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: