Healthcare Provider Details

I. General information

NPI: 1417444845
Provider Name (Legal Business Name): SHALEEN DOCTOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 N MAIN ST
BOUNTIFUL UT
84010-6046
US

IV. Provider business mailing address

390 N MAIN ST
BOUNTIFUL UT
84010-6046
US

V. Phone/Fax

Practice location:
  • Phone: 801-397-6400
  • Fax: 801-396-6439
Mailing address:
  • Phone: 801-397-6400
  • Fax: 801-397-6439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMED-RES-LIC-67437
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12857581
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD204302
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: