Healthcare Provider Details

I. General information

NPI: 1528688264
Provider Name (Legal Business Name): MCKENNA KELLY VANCE BS, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MCKENNA KELLY MORGAN

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 HARRISON BLVD
OGDEN UT
84403-3195
US

IV. Provider business mailing address

100 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-4300
  • Fax:
Mailing address:
  • Phone: 801-662-4100
  • Fax: 801-662-4285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number9428379-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number9428379-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: