Provider Demographics
NPI:1043675994
Name:DICRISTOFANO, MARLEE GOMM (BSN, RN)
Entity type:Individual
Prefix:
First Name:MARLEE
Middle Name:GOMM
Last Name:DICRISTOFANO
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 E 1150 N
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-9100
Mailing Address - Country:US
Mailing Address - Phone:801-368-6723
Mailing Address - Fax:
Practice Address - Street 1:917 E 1150 N
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-9100
Practice Address - Country:US
Practice Address - Phone:801-368-6723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-19
Last Update Date:2015-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4826371-3102163WL0100X, 163WP0807X, 163WN1003X, 163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WN1003XNursing Service ProvidersRegistered NurseNutrition Support
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health