Provider Demographics
NPI:1740955145
Name:BOGGAN, MELISSA JEAN (NP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:BOGGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4883 W UPPER BEND DR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-2073
Mailing Address - Country:US
Mailing Address - Phone:443-854-0691
Mailing Address - Fax:
Practice Address - Street 1:100 N MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:443-854-0691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11014718363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics