Healthcare Provider Details

I. General information

NPI: 1194154989
Provider Name (Legal Business Name): STACEY LYNN COLE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 S CHIPETA WAY
SALT LAKE CITY UT
84108-1287
US

IV. Provider business mailing address

2516 STOCKTON BLVD
SACRAMENTO CA
95817-2208
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-7689
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number223523
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number12985834-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number223523
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA156177
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: