Provider Demographics
NPI:1366273898
Name:SHOCKLEY, COURTNEY LEIGH
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEIGH
Last Name:SHOCKLEY
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 1:348 W PLUM PL
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045-3799
Mailing Address - Country:US
Mailing Address - Phone:210-413-7992
Mailing Address - Fax:
Practice Address - Street 1:721 E 12200 S
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9723
Practice Address - Country:US
Practice Address - Phone:801-368-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13654530-4405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty