Healthcare Provider Details

I. General information

NPI: 1770950636
Provider Name (Legal Business Name): EDLIRA BOZGO FARKA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 S CHIPETA WAY SUITE 200
SLC UT
84108-1260
US

IV. Provider business mailing address

2146 E BROWNING AVE
SLC UT
84108-2250
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2016
  • Fax:
Mailing address:
  • Phone: 801-706-0436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6726852-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: