Healthcare Provider Details

I. General information

NPI: 1114321361
Provider Name (Legal Business Name): MCKEL ANNE ROSKELLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 W 3400 S
OGDEN UT
84401-3376
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-6150
  • Fax: 801-399-2572
Mailing address:
  • Phone: 801-387-6150
  • Fax: 801-399-2572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9565405-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: