Healthcare Provider Details

I. General information

NPI: 1376164061
Provider Name (Legal Business Name): MICHAELA ANTJE SQUIRE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 N MARIO CAPECCHI DR RM 4B096
SALT LAKE CITY UT
84113-1125
US

IV. Provider business mailing address

81 N MARIO CAPECCHI DR RM 4B096
SALT LAKE CITY UT
84113-1125
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 801-581-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number261938
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number14212907-1204
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number14212907-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: