Healthcare Provider Details

I. General information

NPI: 1376078196
Provider Name (Legal Business Name): MARANDA STAR CARLILE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2017
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

352 E RIVERSIDE DR STE A-1A
ST GEORGE UT
84790-6758
US

IV. Provider business mailing address

352 E RIVERSIDE DR STE A-1A
ST GEORGE UT
84790-6758
US

V. Phone/Fax

Practice location:
  • Phone: 435-565-1384
  • Fax: 435-355-3938
Mailing address:
  • Phone: 435-565-1384
  • Fax: 435-355-3938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN002492
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10110
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number375828-4405
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number375828-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: