Provider Demographics
NPI:1568685550
Name:SOUTHWICK, MARTHA FERN (NP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:FERN
Last Name:SOUTHWICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1947 KATE CV
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-6631
Mailing Address - Country:US
Mailing Address - Phone:801-561-2280
Mailing Address - Fax:
Practice Address - Street 1:8541 S REDWOOD RD STE C2
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088
Practice Address - Country:US
Practice Address - Phone:801-432-7712
Practice Address - Fax:866-817-1629
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2000204405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1017129Medicaid