Healthcare Provider Details

I. General information

NPI: 1942958673
Provider Name (Legal Business Name): STEPHANIE ELLIS MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 03/11/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 W COUGAR BLVD STE 104
PROVO UT
84604-3334
US

IV. Provider business mailing address

1121 E 3900 S STE C230
SALT LAKE CITY UT
84124-1297
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-8200
  • Fax: 801-357-8201
Mailing address:
  • Phone: 801-262-9494
  • Fax: 866-415-6807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number7558496-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: