Healthcare Provider Details

I. General information

NPI: 1225828502
Provider Name (Legal Business Name): KALLIE POTHIER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2025
Last Update Date: 08/17/2025
Certification Date: 08/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 S 2000 W UNIT 18A
PLEASANT GROVE UT
84062-3885
US

IV. Provider business mailing address

1532 W 10 S
PLEASANT GROVE UT
84062-6713
US

V. Phone/Fax

Practice location:
  • Phone: 801-382-8645
  • Fax: 866-531-4109
Mailing address:
  • Phone: 208-881-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11590992-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number11590992-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: