Provider Demographics
NPI:1598131310
Name:SMITH, STACEY ODIS
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ODIS
Last Name:SMITH
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 1:1792 W 1700 N
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-1105
Mailing Address - Country:US
Mailing Address - Phone:801-671-1115
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S
Practice Address - Street 2:STE 301
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1700
Practice Address - Country:US
Practice Address - Phone:801-322-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-16
Last Update Date:2015-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker