=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407793805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIRTUAL WELLNESS CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2026
-----------------------------------------------------
Last Update Date | 05/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1038 WEST 8780 SOUTH
-----------------------------------------------------
City | WEST JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-871-9168
-----------------------------------------------------
Fax | 801-780-3082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1038 WEST 8780 SOUTH
-----------------------------------------------------
City | WEST JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-871-9168
-----------------------------------------------------
Fax | 801-780-3082
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FAMILY NURSE PRACTITIONER
-----------------------------------------------------
Name | KAITLIN CONNOLLY
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 801-871-9168
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------