Healthcare Provider Details

I. General information

NPI: 1689396723
Provider Name (Legal Business Name): CON KALEB NEWMAN FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 02/10/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W SR 164
SALEM UT
84653-8465
US

IV. Provider business mailing address

1055 N 500 W ATTN CREDENTIALING
PROVO UT
84604
US

V. Phone/Fax

Practice location:
  • Phone: 801-465-4896
  • Fax: 801-465-0606
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number93965884405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: