Provider Demographics
NPI:1417312604
Name:MONTAGUE, SHANNON MICHELLE (ACNP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MICHELLE
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 S 3000 E
Mailing Address - Street 2:210
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6923
Mailing Address - Country:US
Mailing Address - Phone:435-615-8822
Mailing Address - Fax:
Practice Address - Street 1:6360 S 3000 E
Practice Address - Street 2:210
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6923
Practice Address - Country:US
Practice Address - Phone:435-615-8822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT345074-4405363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care