Healthcare Provider Details

I. General information

NPI: 1578321717
Provider Name (Legal Business Name): SUSAN MARIE BRILLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2024
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

2169 N DITTMAR RD
MILLERSBURG MI
49759-9730
US

V. Phone/Fax

Practice location:
  • Phone: 231-373-2804
  • Fax:
Mailing address:
  • Phone: 231-373-2804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14307439-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: