Healthcare Provider Details

I. General information

NPI: 1902509482
Provider Name (Legal Business Name): KELSIE MARIETTI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 03/23/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 N 575 W
BRIGHAM CITY UT
84302-4455
US

IV. Provider business mailing address

867 N 575 W
BRIGHAM CITY UT
84302-4455
US

V. Phone/Fax

Practice location:
  • Phone: 801-564-9678
  • Fax:
Mailing address:
  • Phone: 801-564-9678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9901000-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: