Healthcare Provider Details

I. General information

NPI: 1033891791
Provider Name (Legal Business Name): ELISSA SUZANNE DRAKE LDEM, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 W ANTELOPE DR
LAYTON UT
84041-1156
US

IV. Provider business mailing address

703 N 1050 W
CLEARFIELD UT
84015-9331
US

V. Phone/Fax

Practice location:
  • Phone: 801-917-6104
  • Fax:
Mailing address:
  • Phone: 801-686-0154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number6225016-3400
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: