MEDICARE: DANIELLE LEIGH FOGG PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	7388179-2402	UT

General Provider Information

NPI Number	:	1740033794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE LEIGH FOGG PTA

Provider Business Mailing Address
First Line	:	1787 E FORT UNION BLVD STE 101
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-2868
Country	:	US
Telephone Number	:	801-997-8881
Fax Number	:

Provider Business Practice Location Address
First Line	:	1787 E FORT UNION BLVD STE 101
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-2868
Country	:	US
Telephone Number	:	801-883-8203
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2024
Last Update Date	:	04/09/2024

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