Healthcare Provider Details

I. General information

NPI: 1699965939
Provider Name (Legal Business Name): KELLI J HURLBURT D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 06/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 S CENTENNIAL PKWY STE 235
SANDY UT
84070-4148
US

IV. Provider business mailing address

10000 S CENTENNIAL PKWY STE 235
SANDY UT
84070-4148
US

V. Phone/Fax

Practice location:
  • Phone: 801-568-4664
  • Fax: 801-568-4665
Mailing address:
  • Phone: 801-568-4664
  • Fax: 801-568-4665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO152388
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7061916-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: