Healthcare Provider Details

I. General information

NPI: 1790470417
Provider Name (Legal Business Name): HAILEE STEWART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2023
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6856 S 700 E
MIDVALE UT
84047-1361
US

IV. Provider business mailing address

4460 S HIGHLAND DR STE 120
SALT LAKE CITY UT
84124-3550
US

V. Phone/Fax

Practice location:
  • Phone: 801-743-6100
  • Fax:
Mailing address:
  • Phone: 888-949-4864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberACM-01928
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: