Provider Demographics
NPI:1265534135
Name:HARRIS, MARY R (APRN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:HARRIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:R
Other - Last Name:CARLSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5171 S COTTONWOOD ST
Practice Address - Street 2:STE 720
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5704
Practice Address - Country:US
Practice Address - Phone:801-507-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT281168-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner