Healthcare Provider Details

I. General information

NPI: 1235637125
Provider Name (Legal Business Name): MICHAEL SHELEKHOV PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 11/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14425 S BITTERBRUSH LN
DRAPER UT
84020
US

IV. Provider business mailing address

4076 S 1610 E
MILLCREEK UT
84124-1521
US

V. Phone/Fax

Practice location:
  • Phone: 801-576-7000
  • Fax:
Mailing address:
  • Phone: 801-669-0060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041375125
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number6381032-3102
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.017270
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number6381032-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: