MEDICARE: MITZI MARIE SIEBERT NURSE PRACTITIONER

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	163WW0101X	Ambulatory Women's Health Care Registered Nurse	208935-4405	UT

General Provider Information

NPI Number	:	1962497768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITZI MARIE SIEBERT NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	7317 MARINDA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-4420
Country	:	US
Telephone Number	:	801-942-0944
Fax Number	:	801-942-0944

Provider Business Practice Location Address
First Line	:	1906 W 3600 S
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84119-4715
Country	:	US
Telephone Number	:	801-973-9675
Fax Number	:	801-973-0379

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

Provider Enumeration Date	:	09/18/2005
Last Update Date	:	07/08/2007

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