Provider Demographics
NPI:1336604610
Name:ELLIS SIMONSEN, SARA MARIE (CNM, MSPH, PHD)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:MARIE
Last Name:ELLIS SIMONSEN
Suffix:
Gender:F
Credentials:CNM, MSPH, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S 2000 E RM 410
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-5880
Mailing Address - Country:US
Mailing Address - Phone:801-585-9360
Mailing Address - Fax:
Practice Address - Street 1:650 ROUND VALLEY DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7571
Practice Address - Country:US
Practice Address - Phone:435-333-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5037536-4402176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5037536-4402OtherCNM LICENSE