Healthcare Provider Details

I. General information

NPI: 1407763808
Provider Name (Legal Business Name): STACY MARIE CARPENTER BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

1393 S 4225 W
SYRACUSE UT
84075-6869
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-1000
  • Fax:
Mailing address:
  • Phone: 801-388-4274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: