Healthcare Provider Details

I. General information

NPI: 1730621459
Provider Name (Legal Business Name): SHEA JOLENE TAYLOR CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2016
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 N 1100 E
AMERICAN FORK UT
84003-2096
US

IV. Provider business mailing address

9967 N 4600 W
CEDAR HILLS UT
84062-8937
US

V. Phone/Fax

Practice location:
  • Phone: 801-855-3300
  • Fax:
Mailing address:
  • Phone: 801-859-2188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4963167-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: