Healthcare Provider Details

I. General information

NPI: 1932654571
Provider Name (Legal Business Name): NGA LORI LY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARIO CAPECCHI DR SALT LAKE CITY UT 84132
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

100 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

V. Phone/Fax

Practice location:
  • Phone: 801-671-3101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7011071-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7011071-8900
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: