Provider Demographics
NPI:1609300383
Name:SMALLEY, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SMALLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 E 800 N
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1209
Mailing Address - Country:US
Mailing Address - Phone:801-794-1490
Mailing Address - Fax:
Practice Address - Street 1:114 E 800 N
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1209
Practice Address - Country:US
Practice Address - Phone:801-794-1490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT204009858174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1821299751OtherNPI
UT1194744615OtherNPI
UT1063481646OtherNPI
UT09858Medicare PIN