Provider Demographics
NPI:1124871942
Name:GAGNON, SHAWNTAE MARIE (CNM, WHNP)
Entity type:Individual
Prefix:
First Name:SHAWNTAE
Middle Name:MARIE
Last Name:GAGNON
Suffix:
Gender:F
Credentials:CNM, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:564 VALERIA DR
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-3314
Mailing Address - Country:US
Mailing Address - Phone:435-730-5329
Mailing Address - Fax:
Practice Address - Street 1:1660 W ANTELOPE DR STE 205
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1165
Practice Address - Country:US
Practice Address - Phone:801-917-6104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11772267-4402367A00000X
UT11772267-4405363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife