Healthcare Provider Details

I. General information

NPI: 1114448529
Provider Name (Legal Business Name): BENJAMIN RUSSEL STUART DNP, APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 S CHILOQUIN BLVD
CHILOQUIN OR
97624-6747
US

IV. Provider business mailing address

2353 E 3225 S
SALT LAKE CITY UT
84109-2719
US

V. Phone/Fax

Practice location:
  • Phone: 541-882-1487
  • Fax:
Mailing address:
  • Phone: 435-881-4809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number5942204-3102
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95035396
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5942204-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: