Healthcare Provider Details

I. General information

NPI: 1598407991
Provider Name (Legal Business Name): CRYSTAL BREKKE MILLER CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 E GATEWAY DR STE 150
HEBER CITY UT
84032-4625
US

IV. Provider business mailing address

1925 E 70 S
HEBER CITY UT
84032-4451
US

V. Phone/Fax

Practice location:
  • Phone: 619-540-0505
  • Fax:
Mailing address:
  • Phone: 619-540-0505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number9102898-4402
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number9102898-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: