Provider Demographics
NPI:1699864801
Name:NIELSEN, SHELLY L (OD)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:L
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:L
Other - Last Name:LEFTWICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1043 N 1000 W
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3897
Mailing Address - Country:US
Mailing Address - Phone:801-919-5154
Mailing Address - Fax:
Practice Address - Street 1:3571 WEST 10400 SOUTH
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095
Practice Address - Country:US
Practice Address - Phone:801-523-5303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5138127-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTV07659Medicare UPIN
UT0618950002Medicare NSC
UT0618950005Medicare NSC
UT004481016Medicare PIN
UT000062881Medicare PIN