Healthcare Provider Details

I. General information

NPI: 1194266148
Provider Name (Legal Business Name): SHANNA FOOTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3197 S 2950 E
ST GEORGE UT
84790-5134
US

IV. Provider business mailing address

3197 S 2950 E
ST GEORGE UT
84790-5134
US

V. Phone/Fax

Practice location:
  • Phone: 208-569-5666
  • Fax:
Mailing address:
  • Phone: 208-569-5666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberAPN0000022036
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number7968495-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: