Provider Demographics
NPI:1790228732
Name:SCHNEIDEWIND, STACY GWEN
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:GWEN
Last Name:SCHNEIDEWIND
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 1:1858 S 200 E APT 10
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2111
Mailing Address - Country:US
Mailing Address - Phone:801-666-1158
Mailing Address - Fax:
Practice Address - Street 1:1858 S 200 E APT 10
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2111
Practice Address - Country:US
Practice Address - Phone:801-666-1158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program