Healthcare Provider Details

I. General information

NPI: 1336646975
Provider Name (Legal Business Name): MILAGROS MIRDO CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2018
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 N BUTLER AVE STE 9102
FARMINGTON NM
87401-3300
US

IV. Provider business mailing address

6405 S 3000 E STE 300
SALT LAKE CITY UT
84121-6977
US

V. Phone/Fax

Practice location:
  • Phone: 832-869-4818
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number53572
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53572
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number106689
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: