Provider Demographics
NPI:1386027373
Name:LANGLEY, MARYELLEN (CRNP/APRN)
Entity type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:LANGLEY
Suffix:
Gender:F
Credentials:CRNP/APRN
Other - Prefix:
Other - First Name:MARYELLEN
Other - Middle Name:
Other - Last Name:LANGLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:25 N 100 E
Mailing Address - Street 2:SUITE #102
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770
Mailing Address - Country:US
Mailing Address - Phone:435-986-2565
Mailing Address - Fax:435-986-2577
Practice Address - Street 1:25 N 100 E
Practice Address - Street 2:SUITE #102
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-986-2565
Practice Address - Fax:435-986-2577
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP015440363LP0808X
UT10209861-4405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103116325-0004Medicaid