Provider Demographics
NPI:1346875325
Name:KILLIAN, SHALESE MARIE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:SHALESE
Middle Name:MARIE
Last Name:KILLIAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:SHALESE
Other - Middle Name:MARIE
Other - Last Name:CONNARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1854
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-1854
Mailing Address - Country:US
Mailing Address - Phone:435-724-3545
Mailing Address - Fax:
Practice Address - Street 1:250 W 300 N
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2336
Practice Address - Country:US
Practice Address - Phone:435-722-4691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9012696-3102163WC0200X
UT9012696-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine