Provider Demographics
NPI:1710439625
Name:MAHAS, STEPHANIE KELLY
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KELLY
Last Name:MAHAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6426 S CANYON COVE DR
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6301
Mailing Address - Country:US
Mailing Address - Phone:801-230-6014
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S
Practice Address - Street 2:STE 310
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:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker