Provider Demographics
NPI:1528431335
Name:BLACK, MAUREEN (RN)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3741 W 12600 S
Mailing Address - Street 2:MOM BABY UNIT
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7215
Mailing Address - Country:US
Mailing Address - Phone:801-285-2303
Mailing Address - Fax:
Practice Address - Street 1:5121 S COTTONWOOD ST
Practice Address - Street 2:IM WOMEN AND CHILDREN ADMINISTRATION 15400-15541
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-507-7673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT290597-3102282NW0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NW0100XHospitalsGeneral Acute Care HospitalWomen
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854057Medicaid