Healthcare Provider Details

I. General information

NPI: 1992249437
Provider Name (Legal Business Name): RONALD M MYLOTT NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 HARRISON BLVD
OGDEN UT
84403-3195
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-2800
  • Fax:
Mailing address:
  • Phone: 801-941-1852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number8306305-3102
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8306305-4405
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8306305-8900
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: