Provider Demographics
NPI:1508592767
Name:MCKELL, MADISEN NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:MADISEN
Middle Name:NICOLE
Last Name:MCKELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:NICOLE
Other - Last Name:MCKELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:3300 N RUNNING CREEK WAY
Practice Address - Street 2:BLDG B STE 100
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043
Practice Address - Country:US
Practice Address - Phone:801-766-4214
Practice Address - Fax:801-418-0941
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT13107950-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program