Healthcare Provider Details

I. General information

NPI: 1205688421
Provider Name (Legal Business Name): EMILEE KELLY AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 E RIVERSIDE DR STE A101
ST GEORGE UT
84790-8147
US

IV. Provider business mailing address

9980 S 300 W STE 300
SANDY UT
84070-3654
US

V. Phone/Fax

Practice location:
  • Phone: 801-253-6886
  • Fax:
Mailing address:
  • Phone: 801-253-6886
  • Fax: 385-900-5928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number6925143-3102
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6925143-4405
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number6925143-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: