Healthcare Provider Details

I. General information

NPI: 1346011152
Provider Name (Legal Business Name): LISA DUNN BAGLEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2024
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5169 S COTTONWOOD ST STE 320
SALT LAKE CITY UT
84107-6768
US

IV. Provider business mailing address

PO BOX 27128
SLC UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-8122
  • Fax:
Mailing address:
  • Phone: 801-507-8122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number308221-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: