Provider Demographics
NPI:1396255360
Name:MUTIE, BERNARD M (APRN)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:M
Last Name:MUTIE
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 S 900 E
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7209
Mailing Address - Country:US
Mailing Address - Phone:801-783-5011
Mailing Address - Fax:801-746-3734
Practice Address - Street 1:12433 S FORT ST
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9363
Practice Address - Country:US
Practice Address - Phone:801-576-1086
Practice Address - Fax:801-576-9796
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT79878114405363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology