Provider Demographics
NPI:1437916129
Name:HARLAN, KELLY HENDERSON (ATC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:HENDERSON
Last Name:HARLAN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3029 N WHISPERING MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84404-9266
Mailing Address - Country:US
Mailing Address - Phone:801-645-9935
Mailing Address - Fax:
Practice Address - Street 1:3895 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2312
Practice Address - Country:US
Practice Address - Phone:801-387-7678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT342773-4810207PS0010X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine