Provider Demographics
NPI:1538147418
Name:STEWART, MITZY D (APRN)
Entity type:Individual
Prefix:
First Name:MITZY
Middle Name:D
Last Name:STEWART
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MITZY
Other - Middle Name:D
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:5689 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5447
Mailing Address - Country:US
Mailing Address - Phone:012-681-7158
Mailing Address - Fax:
Practice Address - Street 1:934 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-7135
Practice Address - Country:US
Practice Address - Phone:801-773-7060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1635594405363LP0808X
UT163559-4405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1635594405Medicaid
UT163559-4405OtherSTATE LICENSE NUMBER
UT1538147418Medicare UPIN
UT003114004Medicare PIN
UTU000073809Medicare PIN
UT163559-4405OtherSTATE LICENSE NUMBER