Healthcare Provider Details

I. General information

NPI: 1457100745
Provider Name (Legal Business Name): KAMILLE THAYNE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2024
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12391 S 4000 W
RIVERTON UT
84096-7012
US

IV. Provider business mailing address

2965 W 3500 S
WEST VALLEY CITY UT
84119-3602
US

V. Phone/Fax

Practice location:
  • Phone: 801-302-1750
  • Fax:
Mailing address:
  • Phone: 801-965-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9421907-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number9421907-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: