Healthcare Provider Details

I. General information

NPI: 1003779794
Provider Name (Legal Business Name): MIRANDA MARY BRENNAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 HARRISON BLVD
OGDEN UT
84403-3195
US

IV. Provider business mailing address

2009 N 4800 W
PLAIN CITY UT
84404-9248
US

V. Phone/Fax

Practice location:
  • Phone: 385-405-6058
  • Fax:
Mailing address:
  • Phone: 385-405-6058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: