Provider Demographics
NPI:1427359199
Name:BRISCOE, STEPHANIE (ST)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BRISCOE
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 ATHERTON DR
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-3470
Mailing Address - Country:US
Mailing Address - Phone:801-716-2289
Mailing Address - Fax:
Practice Address - Street 1:3257 E 3300 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-2246
Practice Address - Country:US
Practice Address - Phone:801-716-2289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7496877-4102171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT27-0926842OtherMEDICARE TAX #