Provider Demographics
NPI:1275127490
Name:FRUIN, CAMMI JO (AGNP-C)
Entity Type:Individual
Prefix:
First Name:CAMMI
Middle Name:JO
Last Name:FRUIN
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1144 N 455 W UNIT 6
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:UT
Mailing Address - Zip Code:84049-6493
Mailing Address - Country:US
Mailing Address - Phone:801-712-0994
Mailing Address - Fax:888-807-7464
Practice Address - Street 1:450 W 910 S STE 203
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-2447
Practice Address - Country:US
Practice Address - Phone:801-712-0994
Practice Address - Fax:888-807-7464
Is Sole Proprietor?:No
Enumeration Date:2021-02-28
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT341638-4405363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology