Provider Demographics
NPI:1629753140
Name:MICKELSEN, WHITNEY (CPM, LDEM)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:
Last Name:MICKELSEN
Suffix:
Gender:F
Credentials:CPM, LDEM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 E 300 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2506
Mailing Address - Country:US
Mailing Address - Phone:435-896-3848
Mailing Address - Fax:
Practice Address - Street 1:4359 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84124-3539
Practice Address - Country:US
Practice Address - Phone:888-755-7155
Practice Address - Fax:801-723-3115
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13330292-3400176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife