Healthcare Provider Details

I. General information

NPI: 1851021018
Provider Name (Legal Business Name): KELLY DISTEFANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2022
Last Update Date: 06/12/2022
Certification Date: 06/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

2165 S 1700 E
SALT LAKE CITY UT
84106-4122
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2953
  • Fax:
Mailing address:
  • Phone: 860-462-8204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number111980483102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: