Healthcare Provider Details

I. General information

NPI: 1184294878
Provider Name (Legal Business Name): LISA MARIE STODDARD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA MARIE WAGNER RN

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5171 S COTTONWOOD ST STE 210
MURRAY UT
84107-5718
US

IV. Provider business mailing address

5179 W NOKASIPPI LN
SOUTH JORDAN UT
84009-6123
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3380
  • Fax: 801-507-8343
Mailing address:
  • Phone: 720-201-3640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8705381-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: