Provider Demographics
NPI:1558040675
Name:DUFUR, MARISSA ANN
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANN
Last Name:DUFUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 N 950 W
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-1099
Mailing Address - Country:US
Mailing Address - Phone:801-830-0017
Mailing Address - Fax:
Practice Address - Street 1:14572 S 790 W
Practice Address - Street 2:
Practice Address - City:BLUFFDALE
Practice Address - State:UT
Practice Address - Zip Code:84065-2371
Practice Address - Country:US
Practice Address - Phone:385-287-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7870638-3102163W00000X
UT7870638-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7870638-4405OtherDOPL-UTAH