Healthcare Provider Details

I. General information

NPI: 1043744931
Provider Name (Legal Business Name): KATHRYN MARIE ALFONSO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN ALFONSO METTLER

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1157 N 300 W STE 201
PROVO UT
84604-6124
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-1200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number14009205-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number14009205-1204
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2021-02218
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number64047
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: