1124175161 NPI number — MARILYN MARIE CHAN EDD MSN MED APRN

Table of content: MARILYN MARIE CHAN EDD MSN MED APRN (NPI 1124175161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124175161 NPI number — MARILYN MARIE CHAN EDD MSN MED APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAN
Provider First Name:
MARILYN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
EDD MSN MED APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JONES
Provider Other First Name:
MARILYN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124175161
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3451 S EASTWOOD DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-272-2682
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8925 SOUTH 2700 WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST JORDAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-566-6200
Provider Business Practice Location Address Fax Number:
801-566-7993
Provider Enumeration Date:
01/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  87-199449-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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