Healthcare Provider Details

I. General information

NPI: 1669071395
Provider Name (Legal Business Name): MEGAN SONJA SULLIVAN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 10/23/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 S 200 E STE 250
SALT LAKE CITY UT
84111-3846
US

IV. Provider business mailing address

11241 S SANDCREST CIR
SANDY UT
84094-7014
US

V. Phone/Fax

Practice location:
  • Phone: 801-359-2256
  • Fax:
Mailing address:
  • Phone: 503-758-2780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7650547-4409
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: