Healthcare Provider Details

I. General information

NPI: 1083278717
Provider Name (Legal Business Name): SHANELL N RICH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3725 W 4100 S
WEST VALLEY CITY UT
84120-5411
US

IV. Provider business mailing address

14198 S CROWN ROSE DR
HERRIMAN UT
84096-6497
US

V. Phone/Fax

Practice location:
  • Phone: 801-965-3600
  • Fax:
Mailing address:
  • Phone: 385-226-1059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1083278717
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number5801043-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: