Provider Demographics
NPI:1417645193
Name:STODDARD, SPENCER ELI
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:ELI
Last Name:STODDARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 N VALLEY VIEW DR APT 701
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5028
Mailing Address - Country:US
Mailing Address - Phone:435-669-3088
Mailing Address - Fax:
Practice Address - Street 1:845 N VALLEY VIEW DR APT 701
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5028
Practice Address - Country:US
Practice Address - Phone:435-669-3088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10455165-4405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health