Healthcare Provider Details

I. General information

NPI: 1366433559
Provider Name (Legal Business Name): KELLY A KELSEY PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 E 200 S SUITE 600
SALT LAKE CITY UT
84111-2048
US

IV. Provider business mailing address

2780 NORA DR
SALT LAKE CITY UT
84124-2026
US

V. Phone/Fax

Practice location:
  • Phone: 801-415-4459
  • Fax:
Mailing address:
  • Phone: 801-274-2782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number377087-1701
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number03-1-20645
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: