Provider Demographics
NPI:1376079061
Name:SHUPE, LORETTA (CPM, RN, LDEM)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:SHUPE
Suffix:
Gender:F
Credentials:CPM, RN, LDEM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 E 2700 N
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-2332
Mailing Address - Country:US
Mailing Address - Phone:801-628-4573
Mailing Address - Fax:
Practice Address - Street 1:5319 S 500 E
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405
Practice Address - Country:US
Practice Address - Phone:801-917-6104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT218152-3102163W00000X
UT218152-3400176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163W00000XNursing Service ProvidersRegistered Nurse