Healthcare Provider Details

I. General information

NPI: 1679876437
Provider Name (Legal Business Name): STEPHANIE LYNN FAGIN P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2010
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 BURNT FORK RD
SALT LAKE CITY UT
84108-1756
US

IV. Provider business mailing address

1112 BURNT FORK RD
SALT LAKE CITY UT
84108-1756
US

V. Phone/Fax

Practice location:
  • Phone: 801-598-8777
  • Fax:
Mailing address:
  • Phone: 801-598-8777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number329509
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number329509-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: