Healthcare Provider Details

I. General information

NPI: 1144584228
Provider Name (Legal Business Name): JERRICA ELIZABETH STODDARD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 11/27/2023
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5640 S 3500 W
ROY UT
84067-9158
US

IV. Provider business mailing address

1055 N 500 W ATTN: CREDENTIALING
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-2838
  • Fax: 801-773-3025
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-1179A
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9098960-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: