MEDICARE: KELLI MARIE CLARKE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0200X	Pediatric Registered Nurse	11129491-3102	UT

General Provider Information

NPI Number	:	1902749302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI MARIE CLARKE

Provider Business Mailing Address
First Line	:	1111 E BRICKYARD RD APT 530
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-4443
Country	:	US
Telephone Number	:	801-662-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 E BRICKYARD RD APT 530
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-4443
Country	:	US
Telephone Number	:	801-662-1000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2026
Last Update Date	:	04/10/2026

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