Provider Demographics
NPI:1659307809
Name:EBERT, SHELLY (FNP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:EBERT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-855-2900
Mailing Address - Fax:801-855-2929
Practice Address - Street 1:10968 N ALPINE HWY
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-8874
Practice Address - Country:US
Practice Address - Phone:801-763-2900
Practice Address - Fax:801-763-2929
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT219649-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000063231Medicare PIN