Provider Demographics
NPI:1437922911
Name:SUTHERLAND, KAYLEE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAYLEE
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4049 S CASTLE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84128-4267
Mailing Address - Country:US
Mailing Address - Phone:208-851-8101
Mailing Address - Fax:
Practice Address - Street 1:434 E 5350 S
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-5418
Practice Address - Country:US
Practice Address - Phone:801-479-7721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT135826811206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant