Provider Demographics
NPI:1215679931
Name:PETTIT, SHAYLEE C (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:SHAYLEE
Middle Name:C
Last Name:PETTIT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5711 S 1475 E STE 201
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5185
Mailing Address - Country:US
Mailing Address - Phone:801-332-9034
Mailing Address - Fax:678-203-9134
Practice Address - Street 1:5711 S 1475 E STE 201
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5185
Practice Address - Country:US
Practice Address - Phone:801-332-9034
Practice Address - Fax:678-203-9134
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8614262-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily