Healthcare Provider Details

I. General information

NPI: 1164450789
Provider Name (Legal Business Name): PATRICE L KENNEDY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL DRIVE
SLC TN
84148
US

IV. Provider business mailing address

7898 SHOWCASE LN
SANDY UT
84094-7252
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone: 801-565-0136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number263948-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: