Healthcare Provider Details

I. General information

NPI: 1215679931
Provider Name (Legal Business Name): SHAYLEE C PETTIT NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5711 S 1475 E STE 201
SOUTH OGDEN UT
84403-5185
US

IV. Provider business mailing address

5711 S 1475 E STE 201
SOUTH OGDEN UT
84403-5185
US

V. Phone/Fax

Practice location:
  • Phone: 801-332-9034
  • Fax: 678-203-9134
Mailing address:
  • Phone: 801-332-9034
  • Fax: 678-203-9134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8614262-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: