=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003635004
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMMA FONG APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2024
-----------------------------------------------------
Last Update Date | 10/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3802 S 700 E
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84106-1182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-264-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 971 W TIFFANY DALE WAY
-----------------------------------------------------
City | BLUFFDALE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84065-1836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-960-0620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 118761824405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 118761824405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------