Healthcare Provider Details

I. General information

NPI: 1598051070
Provider Name (Legal Business Name): MRS. JESSICA TANDY STAHLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 CLOVERDALE RD
NORTH SALT LAKE UT
84054-2323
US

IV. Provider business mailing address

480 CLOVERDALE RD
NORTH SALT LAKE UT
84054-2323
US

V. Phone/Fax

Practice location:
  • Phone: 801-831-0630
  • Fax: 801-797-9412
Mailing address:
  • Phone: 801-831-0630
  • Fax: 801-797-9412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: