Healthcare Provider Details

I. General information

NPI: 1326528779
Provider Name (Legal Business Name): SARAH LYN WAGSTAFF DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 E 3900 S STE 2000
SALT LAKE CITY UT
84124-1236
US

IV. Provider business mailing address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

V. Phone/Fax

Practice location:
  • Phone: 801-266-3418
  • Fax:
Mailing address:
  • Phone: 208-625-5084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5761373
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8152168-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: