Provider Demographics
NPI:1730465873
Name:DUVALL, MICAH TANIEL (FNP)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:TANIEL
Last Name:DUVALL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3152N UNIVERSITY AVE 220
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4746
Mailing Address - Country:US
Mailing Address - Phone:801-229-1014
Mailing Address - Fax:801-229-1067
Practice Address - Street 1:10684 S RIVER FRONT PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-3525
Practice Address - Country:US
Practice Address - Phone:801-816-0332
Practice Address - Fax:801-816-0331
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT361370-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily