Provider Demographics
NPI:1083278717
Name:RICH, SHANELL N (FNP)
Entity Type:Individual
Prefix:
First Name:SHANELL
Middle Name:N
Last Name:RICH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14198 S CROWN ROSE DR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6497
Mailing Address - Country:US
Mailing Address - Phone:385-226-1059
Mailing Address - Fax:
Practice Address - Street 1:3725 W 4100 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-5411
Practice Address - Country:US
Practice Address - Phone:801-965-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5801043-3102163WG0000X
UT1083278717363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Multi-Specialty