Provider Demographics
NPI:1205262474
Name:DORAIS, STACEY M (PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:M
Last Name:DORAIS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:MISS
Other - First Name:STACEY
Other - Middle Name:M
Other - Last Name:PEARSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:201 S 1460 E RM 426
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-9061
Mailing Address - Country:US
Mailing Address - Phone:801-581-6826
Mailing Address - Fax:801-585-6816
Practice Address - Street 1:201 S 1460 E RM 426
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-9061
Practice Address - Country:US
Practice Address - Phone:801-581-6826
Practice Address - Fax:801-585-6816
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT92358484405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health