Healthcare Provider Details

I. General information

NPI: 1699265686
Provider Name (Legal Business Name): KIMBERLEE KOLLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 E 4500 S STE N160
MURRAY UT
84107
US

IV. Provider business mailing address

PO BOX 520009
SALT LAKE CITY UT
84152-0009
US

V. Phone/Fax

Practice location:
  • Phone: 801-281-1100
  • Fax: 801-281-1936
Mailing address:
  • Phone: 801-281-1100
  • Fax: 801-281-1936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: