Healthcare Provider Details

I. General information

NPI: 1073708095
Provider Name (Legal Business Name): STEPHANIE ANN BODILY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MEDICAL DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

4786 VIEWMONT ST
SALT LAKE CITY UT
84117-5333
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-2445
  • Fax: 801-662-2469
Mailing address:
  • Phone: 801-662-2445
  • Fax: 801-662-2469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number222883-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: