Healthcare Provider Details

I. General information

NPI: 1922028497
Provider Name (Legal Business Name): L KRISTIN SHADOW MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0100
US

IV. Provider business mailing address

PO BOX 413029
SALT LAKE CITY UT
84141-3029
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7951
  • Fax:
Mailing address:
  • Phone: 801-213-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number3282171205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number328217-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: