Healthcare Provider Details

I. General information

NPI: 1487560363
Provider Name (Legal Business Name): BENNITA J GAGE CPM, LDEM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5336 HOLLOW RD
LOGAN UT
84321-7920
US

IV. Provider business mailing address

5336 HOLLOW RD
LOGAN UT
84321-7920
US

V. Phone/Fax

Practice location:
  • Phone: 435-225-6370
  • Fax:
Mailing address:
  • Phone: 435-225-6370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number14280802-3400
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: