Healthcare Provider Details

I. General information

NPI: 1376062752
Provider Name (Legal Business Name): STACIE EGAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2017
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5740 CRESTWOOD DR
OGDEN UT
84405-4869
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-3380
  • Fax: 801-475-3381
Mailing address:
  • Phone: 801-475-3075
  • Fax: 801-475-3076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number7979937-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: