Healthcare Provider Details

I. General information

NPI: 1780619627
Provider Name (Legal Business Name): KATHLEEN MARY KUNTZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA MEDICAL CTR 500 FOOTHILL DRIVE
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

1116 3RD AVE
SALT LAKE CITY UT
84103-4118
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax: 801-584-1273
Mailing address:
  • Phone: 801-582-1565
  • Fax: 801-584-1273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number5084653-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: