Provider Demographics
NPI:1497140172
Name:KROENCKE, RACHEL
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:KROENCKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N 1900 E
Mailing Address - Street 2:4C116
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0002
Mailing Address - Country:US
Mailing Address - Phone:801-581-7899
Mailing Address - Fax:
Practice Address - Street 1:30 N 1900 E
Practice Address - Street 2:4C116
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0002
Practice Address - Country:US
Practice Address - Phone:801-581-7899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT10100634-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program