Healthcare Provider Details

I. General information

NPI: 1659307809
Provider Name (Legal Business Name): SHELLY EBERT F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10968 N ALPINE HWY
HIGHLAND UT
84003-8874
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-763-2900
  • Fax: 801-763-2929
Mailing address:
  • Phone: 801-855-2900
  • Fax: 801-855-2929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number219649-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: