MEDICARE: MARY DANIELLE KUYKENDALL PMHNP, APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	77110	ID
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	8658127-4405	UT

General Provider Information

NPI Number	:	1609556596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY DANIELLE KUYKENDALL PMHNP, APRN

Provider Business Mailing Address
First Line	:	PO BOX 850
Second Line	:
City	:	OAKLEY
State	:	UT
Zip	:	84055-0801
Country	:	US
Telephone Number	:	801-696-2444
Fax Number	:

Provider Business Practice Location Address
First Line	:	60 E 3750 S
Second Line	:
City	:	SOUTH SALT LAKE
State	:	UT
Zip	:	84115-4428
Country	:	US
Telephone Number	:	801-486-0911
Fax Number	:	801-262-3709

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2023
Last Update Date	:	04/11/2025

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