Provider Demographics
NPI:1619550688
Name:KIELY, LILY MAEVE
Entity Type:Individual
Prefix:
First Name:LILY
Middle Name:MAEVE
Last Name:KIELY
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 1:375 S CHIPETA WAY STE A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1261
Mailing Address - Country:US
Mailing Address - Phone:801-581-7766
Mailing Address - Fax:
Practice Address - Street 1:375 S CHIPETA WAY STE A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1261
Practice Address - Country:US
Practice Address - Phone:801-581-7766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2022-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13000083-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant