=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902535107
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEFANIE SIMONS CAMASSI AGNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2022
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1878 W 12600 S STE 336
-----------------------------------------------------
City | RIVERTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84065-7026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-879-9104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14286 S JACKSON FIELD WAY
-----------------------------------------------------
City | HERRIMAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84096-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-879-9104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 7960610-4405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 7960610-4405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------