Healthcare Provider Details

I. General information

NPI: 1861155228
Provider Name (Legal Business Name): SHANE A ARCHIBALD RN, DNP, APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 S 400 E STE 100
BOUNTIFUL UT
84010-4862
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-397-6200
  • Fax: 801-397-6201
Mailing address:
  • Phone: 801-475-3500
  • Fax: 801-475-3414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7672413-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: