=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942999511
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKE HOLLY SHELTON FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2023
-----------------------------------------------------
Last Update Date | 08/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 830 N 2000 W
-----------------------------------------------------
City | PLEASANT GROVE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84062-4047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-208-8850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 659 E WYNGATE POINTE LN
-----------------------------------------------------
City | DRAPER
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84020-9695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-208-8850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 10408063-4405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------