Healthcare Provider Details

I. General information

NPI: 1215520234
Provider Name (Legal Business Name): MICHELLE SHEPHERD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2021
Last Update Date: 02/20/2021
Certification Date: 02/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 N UNIVERSITY AVE
PROVO UT
84604-5504
US

IV. Provider business mailing address

1559 S BRIDLE PATH LOOP
LEHI UT
84043-5006
US

V. Phone/Fax

Practice location:
  • Phone: 801-932-2951
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number6683081-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: