Provider Demographics
NPI:1730175761
Name:DALTON, MARLEE K (CNM, ARPN)
Entity type:Individual
Prefix:
First Name:MARLEE
Middle Name:K
Last Name:DALTON
Suffix:
Gender:F
Credentials:CNM, ARPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2376 N 400 E STE 203
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-3413
Mailing Address - Country:US
Mailing Address - Phone:435-882-0599
Mailing Address - Fax:435-882-2111
Practice Address - Street 1:2376 N 400 E STE 203
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-3413
Practice Address - Country:US
Practice Address - Phone:435-882-0599
Practice Address - Fax:435-880-2039
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT264241-4405363LW0102X
UT264241-4402367A00000X
UT2642414405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1730175761Medicaid
UT264241411002001OtherREGENCE BCBS
UTQ15314Medicare UPIN
UTFNP PTAN# 005740816Medicare PIN
UT264241411002001OtherREGENCE BCBS