Healthcare Provider Details

I. General information

NPI: 1376079061
Provider Name (Legal Business Name): LORETTA SHUPE C.P.M., R.N., LDEM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5319 S 500 E
OGDEN UT
84405
US

IV. Provider business mailing address

431 E 2700 N
NORTH OGDEN UT
84414-2332
US

V. Phone/Fax

Practice location:
  • Phone: 801-917-6104
  • Fax:
Mailing address:
  • Phone: 801-628-4573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number218152-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number218152-3400
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: