MEDICARE: DONNA M. WAHOFF-STICE APRN, FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	205110-4405	UT

General Provider Information

NPI Number	:	1013007608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA M. WAHOFF-STICE APRN, FNP

Provider Business Mailing Address
First Line	:	PO BOX 581700
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84158-1700
Country	:	US
Telephone Number	:	801-213-3800
Fax Number	:

Provider Business Practice Location Address
First Line	:	615 ARAPEEN DR
Second Line	:	100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1267
Country	:	US
Telephone Number	:	801-581-7761
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	07/09/2007

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