Provider Demographics
NPI:1982288486
Name:HENDERSON, STACIE (PA)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:RENE DE JESUS
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN. CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:972 N 600 E
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1306
Practice Address - Country:US
Practice Address - Phone:801-465-4896
Practice Address - Fax:801-465-3267
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
UT13182462-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program