Provider Demographics
NPI:1508293325
Name:WALLACE, STEPHANIE (RN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175B CONNOR RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-5002
Mailing Address - Country:US
Mailing Address - Phone:385-202-5320
Mailing Address - Fax:
Practice Address - Street 1:127 S 500 E
Practice Address - Street 2:SUITE 140
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1959
Practice Address - Country:US
Practice Address - Phone:801-587-6658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-11
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8317159-3102163W00000X
CA843676163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse