Healthcare Provider Details

I. General information

NPI: 1326222175
Provider Name (Legal Business Name): MILADA TICHY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5848 S 300 E
MURRAY UT
84107-6157
US

IV. Provider business mailing address

7777 S REDWOOD RD
WEST JORDAN UT
84084-5518
US

V. Phone/Fax

Practice location:
  • Phone: 801-314-4100
  • Fax:
Mailing address:
  • Phone: 801-255-9077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number52324934405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5232493-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: