Healthcare Provider Details

I. General information

NPI: 1548501281
Provider Name (Legal Business Name): STACY WOJCIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 S MAIN ST
BLANDING UT
84511-3830
US

IV. Provider business mailing address

356 S MAIN ST
BLANDING UT
84511-3830
US

V. Phone/Fax

Practice location:
  • Phone: 435-678-2992
  • Fax: 435-678-3116
Mailing address:
  • Phone: 435-678-2992
  • Fax: 435-678-3116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number277559-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: