Healthcare Provider Details

I. General information

NPI: 1134116783
Provider Name (Legal Business Name): KELLY R AMANN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3485 W 5200 S
ROY UT
84067-9438
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-3900
  • Fax: 801-475-3901
Mailing address:
  • Phone: 801-475-3900
  • Fax: 801-475-3901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number49040751204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: