Healthcare Provider Details

I. General information

NPI: 1134596257
Provider Name (Legal Business Name): MAKINZEE RAE KEMP PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2015
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W 2700 N
PLEASANT VIEW UT
84404-4791
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-3600
  • Fax: 801-475-3601
Mailing address:
  • Phone: 801-475-3600
  • Fax: 801-475-3601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9515787-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: