Provider Demographics
NPI:1922301183
Name:GILLEN, SHAWNA JEAN
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:JEAN
Last Name:GILLEN
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 1:355 DIMAGGIO DR
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9297
Mailing Address - Country:US
Mailing Address - Phone:801-355-2846
Mailing Address - Fax:801-359-3244
Practice Address - Street 1:660 S 200 E STE 308
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3853
Practice Address - Country:US
Practice Address - Phone:801-355-2086
Practice Address - Fax:801-359-3244
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health