1699864801 NPI number — SHELLY L NIELSEN OD

Table of content: SHELLY L NIELSEN OD (NPI 1699864801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699864801 NPI number — SHELLY L NIELSEN OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIELSEN
Provider First Name:
SHELLY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEFTWICH
Provider Other First Name:
SHELLY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699864801
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1043 N 1000 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMERICAN FORK
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84003-3897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-919-5154
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3571 WEST 10400 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH JORDAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-523-5303
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  5138127-9934 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)