1992489769 NPI number — DR. KENDALL KATHERINE NELSON APRN

Table of content: DR. KENDALL KATHERINE NELSON APRN (NPI 1992489769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992489769 NPI number — DR. KENDALL KATHERINE NELSON APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
KENDALL
Provider Middle Name:
KATHERINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCUNE
Provider Other First Name:
KENDALL
Provider Other Middle Name:
KATHERINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992489769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1768 E KENSINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84108-2601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-205-5005
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5121 S COTTONWOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURRAY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84107-5701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-205-5005
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  10231000-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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