Healthcare Provider Details

I. General information

NPI: 1407414980
Provider Name (Legal Business Name): MIRACLE MIDWIFERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 S FORT LN STE 1B
LAYTON UT
84041-5700
US

IV. Provider business mailing address

360 S FORT LN STE 1B
LAYTON UT
84041-5700
US

V. Phone/Fax

Practice location:
  • Phone: 801-923-8806
  • Fax: 801-447-6037
Mailing address:
  • Phone: 801-923-8806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number StateNULL

VIII. Authorized Official

Name: KRISTA LYNN MIRACLE
Title or Position: MIDWIFE
Credential: CPM, LM
Phone: 801-923-8806