Healthcare Provider Details

I. General information

NPI: 1730516220
Provider Name (Legal Business Name): STEPHEN LAMARR SCOVILLE APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2013
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5788 S WATERBURY WAY UNIT B
SALT LAKE CITY UT
84121-1141
US

IV. Provider business mailing address

1115 S 900 E
SALT LAKE CITY UT
84105-1323
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-9098
  • Fax:
Mailing address:
  • Phone: 801-662-9098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7427208-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: