Healthcare Provider Details

I. General information

NPI: 1154003473
Provider Name (Legal Business Name): STACEY MILLS LAKE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2023
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 E MURRAY HOLLADAY RD STE 207
HOLLADAY UT
84117-5093
US

IV. Provider business mailing address

2965 W 3500 S
WEST VALLEY CITY UT
84119-3602
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-2584
  • Fax:
Mailing address:
  • Phone: 801-965-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5641317-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5641317-4405
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number5641317-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: