=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790545697
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD FREDRICK STACEY APRN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2024
-----------------------------------------------------
Last Update Date | 03/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8556 N HIGHWAY 38
-----------------------------------------------------
City | HONEYVILLE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84314-9720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-881-0553
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8556 N HIGHWAY 38
-----------------------------------------------------
City | HONEYVILLE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84314-9720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-881-0553
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 13789662-4405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------