Provider Demographics
NPI:1013557487
Name:PETERSEN, STEPHANIE MARIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 W 200 N
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-9711
Mailing Address - Country:US
Mailing Address - Phone:385-888-5320
Mailing Address - Fax:
Practice Address - Street 1:1370 W 200 N
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-9711
Practice Address - Country:US
Practice Address - Phone:385-888-5320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT344963-17011835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist