Provider Demographics
NPI:1568449619
Name:FISHER, SUE ELLEN (PHD, APRN)
Entity type:Individual
Prefix:DR
First Name:SUE
Middle Name:ELLEN
Last Name:FISHER
Suffix:
Gender:F
Credentials:PHD, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2994 TOLCATE LN
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-1529
Mailing Address - Country:US
Mailing Address - Phone:801-278-4598
Mailing Address - Fax:
Practice Address - Street 1:2994 TOLCATE LN
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-1529
Practice Address - Country:US
Practice Address - Phone:801-278-4598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1947254405163WP0809X
UT194725-4405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU006 107001404101OtherINTRMTN. HEALTH CARE
UTU002 262141OtherDESERET MUTUAL
UTU003 942938348F11OtherEDUCATORS MUTUAL
UTU009 942938348OtherCHAMPUS
UTU009 942938348OtherCHAMPUS
UTRCAR 004662169Medicare ID - Type UnspecifiedRAILROAD MEDICARE
UTCARE 004662169Medicare ID - Type UnspecifiedMEDICARE
UTMF0116788OtherDEA
UTU009 942938348OtherCHAMPUS
UTU003 942938348F11OtherEDUCATORS MUTUAL
UTU002 262141OtherDESERET MUTUAL