Healthcare Provider Details

I. General information

NPI: 1194968651
Provider Name (Legal Business Name): VALERY LYNN SHAW RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 04/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S MEDICAL DR
MOUNT PLEASANT UT
84647-2222
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 435-462-4631
  • Fax: 801-442-0066
Mailing address:
  • Phone: 435-462-4631
  • Fax: 801-442-0066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number847620
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: