Healthcare Provider Details

I. General information

NPI: 1699252742
Provider Name (Legal Business Name): SHAUNA SKOG RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2018
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 E SYLVAN AVE
SALT LAKE CITY UT
84108-3127
US

IV. Provider business mailing address

2002 E SYLVAN AVE
SALT LAKE CITY UT
84108-3127
US

V. Phone/Fax

Practice location:
  • Phone: 801-916-8698
  • Fax:
Mailing address:
  • Phone: 180-148-5177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number191211-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: