1710180591 NPI number — STACIE B CARTER MSN, CNM

Table of content: STACIE B CARTER MSN, CNM (NPI 1710180591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710180591 NPI number — STACIE B CARTER MSN, CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARTER
Provider First Name:
STACIE
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN, CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GIBBINS
Provider Other First Name:
STACIE
Provider Other Middle Name:
CARTER
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1710180591
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1580 W ANTELOPE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAYTON
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84041-1160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-776-0880
Provider Business Mailing Address Fax Number:
801-773-7399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1580 W ANTELOPE DR
Provider Second Line Business Practice Location Address:
SUITE 290
Provider Business Practice Location Address City Name:
LAYTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84041-1160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-776-0880
Provider Business Practice Location Address Fax Number:
801-773-7399
Provider Enumeration Date:
06/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1710180591 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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