Provider Demographics
NPI:1740600618
Name:SHAFFER, JOANNA KEELE (RN)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:KEELE
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:942 N 1250 E
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 E 200 S
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-2763
Practice Address - Country:US
Practice Address - Phone:435-843-2000
Practice Address - Fax:435-843-2090
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8145475-3102310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility