Healthcare Provider Details

I. General information

NPI: 1609469949
Provider Name (Legal Business Name): CORTNEY ANNE SHUMWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 S 300 W
BLANDING UT
84511-3921
US

IV. Provider business mailing address

466 W 800 S
BLANDING UT
84511-3901
US

V. Phone/Fax

Practice location:
  • Phone: 435-678-0700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number9645214-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: