Healthcare Provider Details

I. General information

NPI: 1821583519
Provider Name (Legal Business Name): DR. SHALISE HALI OWENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 W 500 S STE 210
BOUNTIFUL UT
84010-7254
US

IV. Provider business mailing address

320 W 500 S STE 210
BOUNTIFUL UT
84010-7254
US

V. Phone/Fax

Practice location:
  • Phone: 801-797-9121
  • Fax:
Mailing address:
  • Phone: 801-797-9121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8642517-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: