Provider Demographics
NPI:1013007608
Name:WAHOFF-STICE, DONNA M (APRN, FNP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:WAHOFF-STICE
Suffix:
Gender:F
Credentials:APRN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 581700
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84158-1700
Mailing Address - Country:US
Mailing Address - Phone:801-213-3800
Mailing Address - Fax:
Practice Address - Street 1:615 ARAPEEN DR
Practice Address - Street 2:100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1267
Practice Address - Country:US
Practice Address - Phone:801-581-7761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT205110-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP28431Medicare UPIN
UT0080007016Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER