Provider Demographics
NPI:1558060954
Name:SMITH, STEPHANIE (A-GNP-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:A-GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13614 S VESTRY RD
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7521
Mailing Address - Country:US
Mailing Address - Phone:801-580-1717
Mailing Address - Fax:
Practice Address - Street 1:13957 S BANGERTER PKWY STE 102
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5429
Practice Address - Country:US
Practice Address - Phone:801-866-8619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT359858-4405363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health