MEDICARE: MRS. JEANINE GAIL STETTLER PNP

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	163WP0200X	Pediatric Registered Nurse	RN00120703	WA

General Provider Information

NPI Number	:	1841284056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JEANINE GAIL STETTLER PNP

Provider Business Mailing Address
First Line	:	7561 S 2050 E
Second Line	:
City	:	SOUTH WEBER
State	:	UT
Zip	:	84405-9646
Country	:	US
Telephone Number	:	801-476-4508
Fax Number	:	801-586-4018

Provider Business Practice Location Address
First Line	:	7321 11TH ST
Second Line	:
City	:	HILL AFB
State	:	UT
Zip	:	84056-5012
Country	:	US
Telephone Number	:	801-777-7109
Fax Number	:	777-586-4018

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

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	07/08/2007

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