Provider Demographics
NPI:1356167985
Name:GATES, CHANEL (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:GATES
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 S CONNOR ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-2401
Mailing Address - Country:US
Mailing Address - Phone:801-809-7145
Mailing Address - Fax:
Practice Address - Street 1:1221 S VALLEY GROVE WAY STE 160
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-6758
Practice Address - Country:US
Practice Address - Phone:801-477-7189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10196181-4405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health