Healthcare Provider Details

I. General information

NPI: 1629508403
Provider Name (Legal Business Name): KELSEY BYWATER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

984 MEDICAL DR STE 1
BRIGHAM CITY UT
84302-4712
US

IV. Provider business mailing address

984 MEDICAL DR STE 1
BRIGHAM CITY UT
84302-4712
US

V. Phone/Fax

Practice location:
  • Phone: 435-723-5248
  • Fax: 877-395-5866
Mailing address:
  • Phone: 435-723-5248
  • Fax: 877-395-5866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number337245-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: