Healthcare Provider Details

I. General information

NPI: 1548043029
Provider Name (Legal Business Name): KELLY CROSS IMLAY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 02/11/2026
Certification Date: 02/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1857 N 1000 W STE 1
CLINTON UT
84015-8969
US

IV. Provider business mailing address

1857 N 1000 W STE 1
CLINTON UT
84015-8969
US

V. Phone/Fax

Practice location:
  • Phone: 801-745-5794
  • Fax:
Mailing address:
  • Phone: 801-745-5794
  • Fax: 610-273-5812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number196456-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: