Healthcare Provider Details

I. General information

NPI: 1114961927
Provider Name (Legal Business Name): HOLLY L MARTIN MSN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL DRIVE
SLC UT
84148
US

IV. Provider business mailing address

1086 S 900 E
SLC UT
84105
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number141949-8500
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: