Provider Demographics
NPI:1679346068
Name:PHILLIPS, KELLY JO (APRN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2426 N 840 W
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-3404
Mailing Address - Country:US
Mailing Address - Phone:801-404-4942
Mailing Address - Fax:
Practice Address - Street 1:8686 S 1300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-1947
Practice Address - Country:US
Practice Address - Phone:801-997-0368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7964962-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily