Provider Demographics
NPI:1124175161
Name:CHAN, MARILYN MARIE (EDD MSN MED APRN)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:MARIE
Last Name:CHAN
Suffix:
Gender:F
Credentials:EDD MSN MED APRN
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:MARIE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3451 S EASTWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109
Mailing Address - Country:US
Mailing Address - Phone:801-272-2682
Mailing Address - Fax:
Practice Address - Street 1:8925 SOUTH 2700 WEST
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84044
Practice Address - Country:US
Practice Address - Phone:801-566-6200
Practice Address - Fax:801-566-7993
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT87-199449-4405363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics