Basic Information
Provider Information | |||||||||
NPI: | 1639777212 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEPHENS | ||||||||
FirstName: | CLARISSA | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MORRISSEY | ||||||||
OtherFirstName: | CLARISSA | ||||||||
OtherMiddleName: | NICOLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 708760 | ||||||||
Address2: |   | ||||||||
City: | SANDY | ||||||||
State: | UT | ||||||||
PostalCode: | 840708760 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013529500 | ||||||||
FaxNumber: | 8013527976 | ||||||||
Practice Location | |||||||||
Address1: | 566 RUIN CREEK RD | ||||||||
Address2: |   | ||||||||
City: | HENDERSON | ||||||||
State: | NC | ||||||||
PostalCode: | 275362927 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2524384143 | ||||||||
FaxNumber: | 2524361351 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/15/2020 | ||||||||
LastUpdateDate: | 12/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5013658 | NC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LF0000X | 5013658 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.