Provider Demographics
NPI:1124676044
Name:TIMOTHY, MARIE R (FNP)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:R
Last Name:TIMOTHY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 N 1700 W
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-8803
Mailing Address - Country:US
Mailing Address - Phone:801-773-4840
Mailing Address - Fax:801-525-3164
Practice Address - Street 1:1750 E 3100 N
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040-2406
Practice Address - Country:US
Practice Address - Phone:801-773-4840
Practice Address - Fax:801-525-3164
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT327899-4405363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055266OtherMEDICARE PIN
UT8760003008007Medicaid
UT260022408OtherRAILROAD MEDICARE
UTU000113063Medicaid