Healthcare Provider Details

I. General information

NPI: 1376055111
Provider Name (Legal Business Name): ALLYSE KATHRYN NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 E 1300 N
LOGAN UT
84341-2570
US

IV. Provider business mailing address

3025 W 75 N
LAYTON UT
84041-5747
US

V. Phone/Fax

Practice location:
  • Phone: 435-792-6500
  • Fax:
Mailing address:
  • Phone: 801-513-9953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

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: