Healthcare Provider Details

I. General information

NPI: 1346082641
Provider Name (Legal Business Name): KELLEY NICOLE KEENAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4685 S HIGHLAND DR STE 208
HOLLADAY UT
84117-5163
US

IV. Provider business mailing address

4685 S HIGHLAND DR STE 208
HOLLADAY UT
84117-5163
US

V. Phone/Fax

Practice location:
  • Phone: 385-401-2895
  • Fax:
Mailing address:
  • Phone: 385-401-2895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number13469151-4402
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: