Provider Demographics
NPI:1033891791
Name:DRAKE, ELISSA SUZANNE (LDEM, CPM)
Entity Type:Individual
Prefix:MRS
First Name:ELISSA
Middle Name:SUZANNE
Last Name:DRAKE
Suffix:
Gender:F
Credentials:LDEM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 N 1050 W
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-9331
Mailing Address - Country:US
Mailing Address - Phone:801-686-0154
Mailing Address - Fax:
Practice Address - Street 1:1660 W ANTELOPE DR
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1156
Practice Address - Country:US
Practice Address - Phone:801-917-6104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6225016-3400176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife