MEDICARE: STACEY MILLS LAKE NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	5641317-4405	UT
2	363L00000X	Nurse Practitioner	5641317-4405	UT
3	363LP2300X	Primary Care Nurse Practitioner	5641317-4405	UT

General Provider Information

NPI Number	:	1154003473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY MILLS LAKE NP

Provider Business Mailing Address
First Line	:	2965 W 3500 S
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84119-3602
Country	:	US
Telephone Number	:	801-965-3600
Fax Number	:

Provider Business Practice Location Address
First Line	:	999 E MURRAY HOLLADAY RD STE 207
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84117-5093
Country	:	US
Telephone Number	:	801-268-2584
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2023
Last Update Date	:	01/22/2025

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Directions to “ STACEY MILLS LAKE NP” Practice Location

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