Healthcare Provider Details

I. General information

NPI: 1245032432
Provider Name (Legal Business Name): DONNA L KICIN AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 W 8760 S
WEST JORDAN UT
84088-9397
US

IV. Provider business mailing address

1755 W 8760 S
WEST JORDAN UT
84088-9397
US

V. Phone/Fax

Practice location:
  • Phone: 385-267-3951
  • Fax: 385-304-4749
Mailing address:
  • Phone: 385-267-3951
  • Fax: 385-304-4749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number10496682-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: