Provider Demographics
NPI:1063303717
Name:WAHLSTROM, SHELLY JO (CHT, PHD)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:JO
Last Name:WAHLSTROM
Suffix:
Gender:F
Credentials:CHT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2827 W 4400 S
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-8951
Mailing Address - Country:US
Mailing Address - Phone:801-643-3211
Mailing Address - Fax:
Practice Address - Street 1:2827 W 4400 S
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-8951
Practice Address - Country:US
Practice Address - Phone:801-643-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-11
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ374K00000X374K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical PractitionerGroup - Single Specialty