Healthcare Provider Details

I. General information

NPI: 1770148066
Provider Name (Legal Business Name): BROOKS BRENDEN KELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 N 1525 W STE 3B
FARMINGTON UT
84025-4815
US

IV. Provider business mailing address

775 N 1525 W STE 3B
FARMINGTON UT
84025-4815
US

V. Phone/Fax

Practice location:
  • Phone: 801-609-5431
  • Fax:
Mailing address:
  • Phone: 801-609-5431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number14265845-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number0116032687
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberV6040
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: