Provider Demographics
NPI:1942958673
Name:ELLIS, STEPHANIE (MSN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 E 3900 S STE C230
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1297
Mailing Address - Country:US
Mailing Address - Phone:801-262-9494
Mailing Address - Fax:866-415-6807
Practice Address - Street 1:395 W COUGAR BLVD STE 104
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3334
Practice Address - Country:US
Practice Address - Phone:801-357-8200
Practice Address - Fax:801-357-8201
Is Sole Proprietor?:No
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7558496-4405363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health