Provider Demographics
NPI:1750467155
Name:DAUGHARTY LEWIS, KELLIE (APRN)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:DAUGHARTY LEWIS
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:PO BOX 1009
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-1009
Mailing Address - Country:US
Mailing Address - Phone:801-561-8398
Mailing Address - Fax:801-302-0645
Practice Address - Street 1:39 WANDERWOOD WAY
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84092-4866
Practice Address - Country:US
Practice Address - Phone:801-561-8398
Practice Address - Fax:801-302-0645
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT322464-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1750467155Medicaid
UT000012693Medicare PIN
P66958Medicare UPIN
UT1750467155Medicaid