Healthcare Provider Details

I. General information

NPI: 1699594374
Provider Name (Legal Business Name): CANDY MILLER CROCKETT BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 E MEDICAL TOWER DR
MURRAY UT
84107-4872
US

IV. Provider business mailing address

181 E MEDICAL TOWER DR
MURRAY UT
84107-4872
US

V. Phone/Fax

Practice location:
  • Phone: 801-314-4500
  • Fax: 801-314-2909
Mailing address:
  • Phone: 801-314-4500
  • Fax: 801-314-2909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number7036504-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: