Healthcare Provider Details

I. General information

NPI: 1801477286
Provider Name (Legal Business Name): KIMBERLY LYNN TAGG FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2021
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 N 400 E
LOGAN UT
84341-7539
US

IV. Provider business mailing address

1415 N 400 E STE A
LOGAN UT
84341-7539
US

V. Phone/Fax

Practice location:
  • Phone: 435-753-2840
  • Fax: 435-787-9422
Mailing address:
  • Phone: 435-753-2840
  • Fax: 435-787-9422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5644836-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: