Provider Demographics
NPI:1497498059
Name:PETTY, KELCIE
Entity Type:Individual
Prefix:
First Name:KELCIE
Middle Name:
Last Name:PETTY
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 1:1806 N DIXIE DOWNS RD UNIT 45
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5657
Mailing Address - Country:US
Mailing Address - Phone:801-867-1971
Mailing Address - Fax:
Practice Address - Street 1:1806 N DIXIE DOWNS RD UNIT 45
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5657
Practice Address - Country:US
Practice Address - Phone:435-669-5889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program