Provider Demographics
NPI:1083705735
Name:MORTENSON, KIMBERLY (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MORTENSON
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 1:48 N 1100 E
Mailing Address - Street 2:SUITE C
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2910
Mailing Address - Country:US
Mailing Address - Phone:801-492-4933
Mailing Address - Fax:801-492-4371
Practice Address - Street 1:48 N 1100 E
Practice Address - Street 2:SUITE C
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2910
Practice Address - Country:US
Practice Address - Phone:801-492-4933
Practice Address - Fax:801-492-4371
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2756754405364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP00300688OtherPALMETTO
UTQ56758Medicare UPIN
UTP00300688OtherPALMETTO