Provider Demographics
NPI:1124197512
Name:BLEAK, SHIRLEY JEAN (FNP-C, MSN, RNC)
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:JEAN
Last Name:BLEAK
Suffix:
Gender:F
Credentials:FNP-C, MSN, RNC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1121 E 3900 S
Mailing Address - Street 2:SUITE C-230
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1214
Mailing Address - Country:US
Mailing Address - Phone:801-262-9494
Mailing Address - Fax:801-262-0507
Practice Address - Street 1:5131 COTTONWOOD ST
Practice Address - Street 2:L-2
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-263-3415
Practice Address - Fax:801-263-3428
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT193402-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000065726Medicare PIN