Healthcare Provider Details

I. General information

NPI: 1568242576
Provider Name (Legal Business Name): JUSTIN STANSFIELD NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2023
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S DEPOT DR
OGDEN UT
84404-5573
US

IV. Provider business mailing address

5434 S 3675 W
ROY UT
84067-9243
US

V. Phone/Fax

Practice location:
  • Phone: 801-778-6700
  • Fax:
Mailing address:
  • Phone: 801-726-3578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9415330-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: