Healthcare Provider Details

I. General information

NPI: 1033951595
Provider Name (Legal Business Name): LACEY KAY GORDON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 W 3400 S
OGDEN UT
84401-3376
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-6150
  • Fax: 801-399-2572
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9139307-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: