=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750874129
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE NICOLE UTZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2018
-----------------------------------------------------
Last Update Date | 06/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 GREAT CIRCLE RD STE 202
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37228-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-226-2840
-----------------------------------------------------
Fax | 615-226-2839
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1055 PINE ST APT 240
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37203-4087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-479-1448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------