Healthcare Provider Details

I. General information

NPI: 1609514496
Provider Name (Legal Business Name): SHAYLEY RAE DOCKSTADER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5475 S 500 E
OGDEN UT
84405-6905
US

IV. Provider business mailing address

5475 S 500 E
OGDEN UT
84405-6905
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-2111
  • Fax:
Mailing address:
  • Phone: 801-479-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9030570-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number90305704405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: