Healthcare Provider Details

I. General information

NPI: 1265799472
Provider Name (Legal Business Name): KYLEEN CARPENTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2012
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 E TRAVERSEPOINT DR
DRAPER UT
84020-5679
US

IV. Provider business mailing address

267 E TRAVERSEPOINT DR
DRAPER UT
84020-5679
US

V. Phone/Fax

Practice location:
  • Phone: 801-553-8300
  • Fax: 801-553-8301
Mailing address:
  • Phone: 801-553-8300
  • Fax: 801-553-8301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number8771462-1205
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: