Provider Demographics
NPI:1619922309
Name:KIESTER, JANET D (ANP)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:D
Last Name:KIESTER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 NORTH VINE ST
Mailing Address - Street 2:#1103 WEST
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103
Mailing Address - Country:US
Mailing Address - Phone:574-252-9520
Mailing Address - Fax:574-258-4278
Practice Address - Street 1:241 NORTH VINE ST
Practice Address - Street 2:#1103 WEST
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103
Practice Address - Country:US
Practice Address - Phone:574-252-9520
Practice Address - Fax:574-258-4278
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002036A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200806270Medicaid
Q57188Medicare UPIN
IN735210BMedicare PIN