Provider Demographics
NPI:1427704139
Name:BENNEE, SHAUNA
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:BENNEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 E CRESTHILL DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4312
Mailing Address - Country:US
Mailing Address - Phone:801-815-0999
Mailing Address - Fax:
Practice Address - Street 1:630 SHEPARD LN
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-3934
Practice Address - Country:US
Practice Address - Phone:801-447-8680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT54896403102363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT54896403102OtherRN LICENSE