Healthcare Provider Details

I. General information

NPI: 1730465873
Provider Name (Legal Business Name): MICAH TANIEL DUVALL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10684 S RIVER FRONT PKWY
SOUTH JORDAN UT
84095-3525
US

IV. Provider business mailing address

3152N UNIVERSITY AVE 220
PROVO UT
84604-4746
US

V. Phone/Fax

Practice location:
  • Phone: 801-816-0332
  • Fax: 801-816-0331
Mailing address:
  • Phone: 801-229-1014
  • Fax: 801-229-1067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number361370-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: