Provider Demographics
NPI:1689314445
Name:NEUMANN, MARLEEN DIAN PARK
Entity type:Individual
Prefix:
First Name:MARLEEN
Middle Name:DIAN PARK
Last Name:NEUMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARLEEN
Other - Middle Name:DIAN
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5121 S COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-507-3462
Practice Address - Fax:801-507-3458
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9034811-4405363L00000X
UT9034811-4905363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty