Healthcare Provider Details

I. General information

NPI: 1124871942
Provider Name (Legal Business Name): SHAWNTAE MARIE GAGNON CNM, WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 W ANTELOPE DR STE 205
LAYTON UT
84041-1165
US

IV. Provider business mailing address

564 VALERIA DR
LAYTON UT
84041-3314
US

V. Phone/Fax

Practice location:
  • Phone: 801-917-6104
  • Fax:
Mailing address:
  • Phone: 435-730-5329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number11772267-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number11772267-4402
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: