Provider Demographics
NPI:1689223968
Name:MAZILLO, MEREDITH LEIGH
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:LEIGH
Last Name:MAZILLO
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 1:6771 S 900 E
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1436
Mailing Address - Country:US
Mailing Address - Phone:801-386-9799
Mailing Address - Fax:
Practice Address - Street 1:6771 S 900 E
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1436
Practice Address - Country:US
Practice Address - Phone:801-386-9799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty