Healthcare Provider Details

I. General information

NPI: 1346875325
Provider Name (Legal Business Name): SHALESE MARIE KILLIAN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHALESE MARIE CONNARY

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 03/21/2020
Certification Date: 03/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W 300 N
ROOSEVELT UT
84066-2336
US

IV. Provider business mailing address

PO BOX 1854
ROOSEVELT UT
84066-1854
US

V. Phone/Fax

Practice location:
  • Phone: 435-722-4691
  • Fax:
Mailing address:
  • Phone: 435-724-3545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number9012696-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9012696-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: