Provider Demographics
NPI:1003302548
Name:MCKINNON, KIM MARIE (NP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8197 S 5140 W
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-2705
Mailing Address - Country:US
Mailing Address - Phone:801-895-6171
Mailing Address - Fax:
Practice Address - Street 1:45 W SEGO LILY DR STE 312
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-3643
Practice Address - Country:US
Practice Address - Phone:801-676-9452
Practice Address - Fax:801-206-9734
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT294366-4405208100000X
UT294366-8900363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily