Healthcare Provider Details

I. General information

NPI: 1386268605
Provider Name (Legal Business Name): MARY BETH LOFGREN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1125
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-1675
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10226062-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: