Provider Demographics
NPI:1851314389
Name:MARK, KATHLEEN (CNM)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MARK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 EAST 6000 SOUTH
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405
Mailing Address - Country:US
Mailing Address - Phone:801-337-5800
Mailing Address - Fax:801-337-5809
Practice Address - Street 1:1525 EAST 6000 SOUTH
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405
Practice Address - Country:US
Practice Address - Phone:801-337-5800
Practice Address - Fax:801-337-5809
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1924744402176B00000X
UT192474-4402367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD0895Medicaid
UT160009437OtherMEDICARE RAILROAD
UT005571306Medicare PIN
UTD0895Medicaid