Healthcare Provider Details

I. General information

NPI: 1669968491
Provider Name (Legal Business Name): KEARSTA KAYLEEN WASHBURN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2018
Last Update Date: 07/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 E 4800 S STE 230
MURRAY UT
84107-5535
US

IV. Provider business mailing address

378 S 400 W
TOOELE UT
84074-2620
US

V. Phone/Fax

Practice location:
  • Phone: 801-716-7008
  • Fax:
Mailing address:
  • Phone: 801-673-5756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6224506-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: