Provider Demographics
NPI:1508851890
Name:WALKER, MARY JEAN (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JEAN
Last Name:WALKER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 S 900 E STE 240
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7210
Mailing Address - Country:US
Mailing Address - Phone:017-835-0118
Mailing Address - Fax:801-746-3734
Practice Address - Street 1:5505 S 900 E STE 240
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84117-7210
Practice Address - Country:US
Practice Address - Phone:801-783-5011
Practice Address - Fax:801-746-3734
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT188868-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP34945Medicare UPIN
UT005582319Medicare ID - Type Unspecified