Healthcare Provider Details

I. General information

NPI: 1356167985
Provider Name (Legal Business Name): CHANEL GATES PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2024
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S VALLEY GROVE WAY STE 160
PLEASANT GROVE UT
84062-6758
US

IV. Provider business mailing address

3005 S CONNOR ST
SALT LAKE CITY UT
84109-2401
US

V. Phone/Fax

Practice location:
  • Phone: 801-477-7189
  • Fax:
Mailing address:
  • Phone: 801-809-7145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10196181-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: