Healthcare Provider Details

I. General information

NPI: 1598987307
Provider Name (Legal Business Name): KELLY JEAN STANKIEWICZ MD, FAAD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 09/23/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

THE DERMATOLOGY HOUSE-1922 PROSPECTOR AVE.
PARK CITY UT
84060
US

IV. Provider business mailing address

THE DERMATOLOGY HOUSE-1922 PROSPECTOR AVE.
PARK CITY UT
84060
US

V. Phone/Fax

Practice location:
  • Phone: 435-602-1918
  • Fax: 435-731-8109
Mailing address:
  • Phone: 435-602-1918
  • Fax: 435-731-8109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036128182
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number10172206-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: