Stacey Mills Lake, NP

Primary specialty

Primary Care Nurse PractitionerTaxonomy code 363LP2300X

License

5641317-4405 Issued in UT

Practice address

999 E Murray Holladay Rd Ste 207
Holladay, UT 84117-5093

Phone

(801) 268-2584

NPI assigned

Aug 4, 2023

Last updated

Jan 22, 2025By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Enrolled in UT

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

Other, 2023

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Granger Medical Clinic PCGroup PAC ID 3476465691, 192 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• St Mark's Hospital Hospital, Salt Lake City, UT, CCN 460047

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Granger Medical Clinic PC

  • Multi-Specialty Clinic/Center
  • West Valley City, UT
  • NPI 1184657041
  Medicare reassignment Care Compare group NPD
• Granger Medical Specialists LLC

  • Clinic/Center
  • West Valley City, UT
  • NPI 1376159368
  Medicare reassignment NPD
• Granger Medical Clinic PC

  • Specialist
  • Salt Lake City, UT
  • NPI 1356425672
  NPD
• Granger Medical Specialists, LLC

  • Multi-Specialty Clinic/Center
  • Salt Lake City, UT
  • NPI 1497441539
  NPD
• Granger Medical Clinic PC

  dba Granger Medical West Jordan

  • Multi-Specialty Clinic/Center
  • West Jordan, UT
  • NPI 1104857549
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Northern Utah Healthcare Corporation

  dba St. Mark's Hospital

  • General Acute Care Hospital
  • Salt Lake City, UT
  • NPI 1164469243
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1691107200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1737504000000",
    "number": "1154003473",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2965 W 3500 S",
            "city": "WEST VALLEY CITY",
            "state": "UT",
            "postal_code": "841193602",
            "telephone_number": "801-965-3600"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "999 E MURRAY HOLLADAY RD STE 207",
            "city": "HOLLADAY",
            "state": "UT",
            "postal_code": "841175093",
            "telephone_number": "801-268-2584"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LAKE",
        "first_name": "STACEY",
        "middle_name": "MILLS",
        "credential": "NP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2023-08-04",
        "last_updated": "2025-01-22",
        "certification_date": "2025-01-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "UT",
            "license": "5641317-4405",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "UT",
            "license": "5641317-4405",
            "primary": false
        },
        {
            "code": "363LP2300X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Primary Care",
            "state": "UT",
            "license": "5641317-4405",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jacob Kenison
• Kristina A. Kill, D.C.
• Kanon Knaphus, LMT
• Christy Kobe, LCSW
• Adrienne Melissa Koffman, LCSW
• Ralph T Larsen, DDS
• Katia Lecuyer, LDEM, CPM
• Hayley Leishman, LCSW
• Shauna Ann Leonard, PA-C
• Victor Likhobabin, PHD

• Primary Care Nurse Practitioner in Holladay, UT
• Providers in Holladay, UT by specialty
• Primary Care Nurse Practitioner in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 22, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.