Healthcare Provider Details

I. General information

NPI: 1861699324
Provider Name (Legal Business Name): STEPHANIE I MERRILL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 UNIVERSITY PARK BLVD
LAYTON UT
84041-1611
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-779-6200
  • Fax: 801-475-1621
Mailing address:
  • Phone: 801-779-6200
  • Fax: 801-475-1621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number54878-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2007013531
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number8133411-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: