Provider Demographics
NPI:1164713491
Name:NIELSON, KELLI J (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:J
Last Name:NIELSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3656 WALL AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-7101
Mailing Address - Country:US
Mailing Address - Phone:801-317-3952
Mailing Address - Fax:
Practice Address - Street 1:3656 WALL AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-7101
Practice Address - Country:US
Practice Address - Phone:801-317-3952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5098259-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist