Healthcare Provider Details

I. General information

NPI: 1003973785
Provider Name (Legal Business Name): KATHERINE DENISE KOLLER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S 100 E
PROVO UT
84606-4649
US

IV. Provider business mailing address

315 S 100 E
PROVO UT
84606-4649
US

V. Phone/Fax

Practice location:
  • Phone: 801-851-8517
  • Fax:
Mailing address:
  • Phone: 801-851-8517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number192852-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: