=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184297129
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY FONUA APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2021
-----------------------------------------------------
Last Update Date | 07/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 E 1400 N STE I
-----------------------------------------------------
City | LOGAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84341-2450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-753-1545
-----------------------------------------------------
Fax | 435-753-3153
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 E 1400 N STE I
-----------------------------------------------------
City | LOGAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84341-2450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-753-1545
-----------------------------------------------------
Fax | 435-753-3153
-----------------------------------------------------
=====================================================
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 | 6973497-4405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------