Healthcare Provider Details

I. General information

NPI: 1437916129
Provider Name (Legal Business Name): KELLY HENDERSON HARLAN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3895 HARRISON BLVD
OGDEN UT
84403-2312
US

IV. Provider business mailing address

3029 N WHISPERING MEADOW LN
PLAIN CITY UT
84404-9266
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-7678
  • Fax:
Mailing address:
  • Phone: 801-645-9935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number342773-4810
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number342773-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: