Provider Demographics
NPI:1346271798
Name:ROBISON, STACY K (APRN)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:K
Last Name:ROBISON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1258 W SOUTH JORDAN PKWY STE 202
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4712
Mailing Address - Country:US
Mailing Address - Phone:801-255-1155
Mailing Address - Fax:801-255-0281
Practice Address - Street 1:1258 W SOUTH JORDAN PKWY STE 202
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4712
Practice Address - Country:US
Practice Address - Phone:801-255-1155
Practice Address - Fax:801-255-0281
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT199062-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP76018Medicare UPIN
UT005767004Medicare ID - Type Unspecified