Healthcare Provider Details

I. General information

NPI: 1760110985
Provider Name (Legal Business Name): SHANNON MARIE EDELMAN AUD, CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5349 ADAMS AVE PKWY
OGDEN UT
84405-4736
US

IV. Provider business mailing address

5349 ADAMS AVE PKWY STE C
OGDEN UT
84405-4736
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-3346
  • Fax: 801-479-0725
Mailing address:
  • Phone: 801-479-3346
  • Fax: 801-479-0725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number12852693-4101
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: