Provider Demographics
NPI:1770747941
Name:ROHAN, MARY LESLIE (APRN-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LESLIE
Last Name:ROHAN
Suffix:
Gender:F
Credentials:APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 UNIVERSITY CIR
Mailing Address - Street 2:STUDENT SERVICE CENTER 190
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84408-1128
Mailing Address - Country:US
Mailing Address - Phone:801-626-6459
Mailing Address - Fax:801-626-7786
Practice Address - Street 1:1128 UNIVERSITY CIR
Practice Address - Street 2:STUDENT SERVICE CENTER 190
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84408-1128
Practice Address - Country:US
Practice Address - Phone:801-626-6459
Practice Address - Fax:801-626-7786
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2244504405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000308011Medicaid
UT32481Medicaid
UT998877666002Medicaid