Healthcare Provider Details

I. General information

NPI: 1114403698
Provider Name (Legal Business Name): ETHAN B SHIPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E 4500 S STE 300
MURRAY UT
84107-4502
US

IV. Provider business mailing address

650 E 4500 S STE 300
MURRAY UT
84107-4502
US

V. Phone/Fax

Practice location:
  • Phone: 801-261-3500
  • Fax:
Mailing address:
  • Phone: 801-261-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5560934-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: