MEDICARE: SHAUNA SKOG RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	191211-4405	UT

General Provider Information

NPI Number	:	1699252742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAUNA SKOG RN

Provider Business Mailing Address
First Line	:	2002 E SYLVAN AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-3127
Country	:	US
Telephone Number	:	180-148-5177
Fax Number	:

Provider Business Practice Location Address
First Line	:	2002 E SYLVAN AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-3127
Country	:	US
Telephone Number	:	801-916-8698
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2018
Last Update Date	:	09/26/2022

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