Provider Demographics
NPI:1669559118
Name:GULLETT, SHANNON L (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:L
Last Name:GULLETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:G
Other - Last Name:BLACKBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5770 S 250 E STE 300
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8100
Mailing Address - Country:US
Mailing Address - Phone:801-314-2500
Mailing Address - Fax:801-314-2501
Practice Address - Street 1:5770 S 250 E STE 300
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-8100
Practice Address - Country:US
Practice Address - Phone:801-314-2500
Practice Address - Fax:801-314-2501
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT602955412052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry