Healthcare Provider Details

I. General information

NPI: 1417510157
Provider Name (Legal Business Name): BREENA MAGLEBY SHEPHERD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 E 6100 S
MURRAY UT
84107-7302
US

IV. Provider business mailing address

7914 S FARM HOUSE LN
MIDVALE UT
84047-2864
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2955
  • Fax:
Mailing address:
  • Phone: 435-893-1651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number8826252-1109
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: