Healthcare Provider Details

I. General information

NPI: 1538616594
Provider Name (Legal Business Name): SHANLEE ROBERTSON COLLINWOOD C.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1148 E 2700 S APT H60
MILLCREEK UT
84106-2647
US

IV. Provider business mailing address

1148 E 2700 S APT 60
SLC UT
84106-2647
US

V. Phone/Fax

Practice location:
  • Phone: 470-588-6464
  • Fax: 801-477-8451
Mailing address:
  • Phone: 470-588-6464
  • Fax: 801-477-8451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM218
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number10513702-3400
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: