Healthcare Provider Details

I. General information

NPI: 1992828958
Provider Name (Legal Business Name): KAYLEEN TERRY A.P.R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 04/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 WOODROW ST STE 102
MURRAY UT
84107-5841
US

IV. Provider business mailing address

5323 WOODROW ST STE 102
MURRAY UT
84107-5841
US

V. Phone/Fax

Practice location:
  • Phone: 801-713-1010
  • Fax: 801-713-0665
Mailing address:
  • Phone: 801-713-1010
  • Fax: 801-713-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number150335-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number150335-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: