Provider Demographics
NPI:1538783949
Name:IRELAND, STACIE MICHELLE (BSN)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:MICHELLE
Last Name:IRELAND
Suffix:
Gender:F
Credentials:BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3402 E STONEHILL LN
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-5864
Mailing Address - Country:US
Mailing Address - Phone:801-884-9220
Mailing Address - Fax:
Practice Address - Street 1:3402 E STONEHILL LN
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-5864
Practice Address - Country:US
Practice Address - Phone:801-884-9220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10640279-4405363LF0000X
UT106402793102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse