Provider Demographics
NPI:1073246161
Name:PETERSON, SHANTEL ELIZABETH (RN)
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:ELIZABETH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 S 100 E
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-5002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:609 S 100 E
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-5002
Practice Address - Country:US
Practice Address - Phone:801-927-7682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3576153102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse