Healthcare Provider Details

I. General information

NPI: 1992659767
Provider Name (Legal Business Name): KIMBERLY SAMANTHA RODRIGUEZ PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA RODRIQUEZ

II. Dates (important events)

Enumeration Date: 02/26/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 W COUGAR BLVD STE 601
PROVO UT
84604-3331
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7525
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11415541-8900
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: