Provider Demographics
NPI:1093206922
Name:THORNE, KELSEY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:THORNE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:GIRARDELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2245 N 400 E STE 201
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1891
Mailing Address - Country:US
Mailing Address - Phone:435-787-7001
Mailing Address - Fax:801-216-8357
Practice Address - Street 1:2245 N 400 E STE 201
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1891
Practice Address - Country:US
Practice Address - Phone:435-787-7001
Practice Address - Fax:801-216-8357
Is Sole Proprietor?:No
Enumeration Date:2018-05-26
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13633355363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT13633355-1206OtherSTATE LICENSE