Basic Information
| Provider Information | |||||||||
| NPI: | 1982997284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7181 S CAMPUS VIEW DR | ||||||||
| Address2: | |||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840844312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019653505 | ||||||||
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| Practice Location | |||||||||
| Address1: | 348 E 4500 S STE 200 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019653600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2011 | ||||||||
| LastUpdateDate: | 09/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | R72652 | AZ | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 10259776-1205 | UT | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.