Provider Demographics
NPI:1124080775
Name:BOLL, MELISSA A (CNM)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:BOLL
Suffix:
Gender:
Credentials:CNM
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:BORRACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:6975 S UNION PARK CTR
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84047-6048
Mailing Address - Country:US
Mailing Address - Phone:888-731-8994
Mailing Address - Fax:833-775-1861
Practice Address - Street 1:6975 S UNION PARK CTR STE 600
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84047-4187
Practice Address - Country:US
Practice Address - Phone:888-731-8994
Practice Address - Fax:888-732-8119
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5713781-4402176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5743Medicaid
UT420000171Medicare ID - Type Unspecified
UTD5743Medicaid