Provider Demographics
NPI:1780205245
Name:MIJARES, NOEMY
Entity Type:Individual
Prefix:
First Name:NOEMY
Middle Name:
Last Name:MIJARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 N 1950 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-3100
Mailing Address - Country:US
Mailing Address - Phone:801-538-4001
Mailing Address - Fax:
Practice Address - Street 1:3450 S 900 W
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84119-4104
Practice Address - Country:US
Practice Address - Phone:801-516-8244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator