Provider Demographics
NPI:1528514809
Name:TILLOTSON, SHADRICK WYATT (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:SHADRICK
Middle Name:WYATT
Last Name:TILLOTSON
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 W BLUE GRASS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4190
Mailing Address - Country:US
Mailing Address - Phone:385-510-5150
Mailing Address - Fax:866-748-5235
Practice Address - Street 1:2901 W BLUE GRASS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-4190
Practice Address - Country:US
Practice Address - Phone:385-510-5150
Practice Address - Fax:866-748-5235
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6223314-4405363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily