Healthcare Provider Details

I. General information

NPI: 1912862814
Provider Name (Legal Business Name): KAYLEE RAY PETERSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2025
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7155 S HIGH TECH DR APT 30
MIDVALE UT
84047-3763
US

IV. Provider business mailing address

7155 S HIGH TECH DR APT 30
MIDVALE UT
84047-3763
US

V. Phone/Fax

Practice location:
  • Phone: 801-227-9891
  • Fax:
Mailing address:
  • Phone: 801-227-9891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10406387-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: