Healthcare Provider Details

I. General information

NPI: 1447583471
Provider Name (Legal Business Name): LEEANN C KLEMETSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12433 FORT ST
DRAPER UT
84020-9363
US

IV. Provider business mailing address

12433 FORT ST
DRAPER UT
84020-9363
US

V. Phone/Fax

Practice location:
  • Phone: 801-576-1086
  • Fax: 801-576-9796
Mailing address:
  • Phone: 801-576-1086
  • Fax: 801-576-9796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number214637-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: