Healthcare Provider Details

I. General information

NPI: 1205025665
Provider Name (Legal Business Name): KELLI DIMOND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 INTERNATIONAL PKWY 2051
HEATHROW FL
32746-5303
US

IV. Provider business mailing address

14077 DEER HAVEN CV
BLUFFDALE UT
84065-5540
US

V. Phone/Fax

Practice location:
  • Phone: 800-798-6035
  • Fax:
Mailing address:
  • Phone: 801-815-1602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number6240616
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: