Provider Demographics
NPI:1003517343
Name:SHIELDS, MISTY R
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:R
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 W PACKSADDLE CIR
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-1299
Mailing Address - Country:US
Mailing Address - Phone:360-597-8320
Mailing Address - Fax:
Practice Address - Street 1:1717 W PACKSADDLE CIR
Practice Address - Street 2:
Practice Address - City:BLUFFDALE
Practice Address - State:UT
Practice Address - Zip Code:84065-1299
Practice Address - Country:US
Practice Address - Phone:360-597-8320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6960909-8900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health