Provider Demographics
NPI:1790071033
Name:BOTT, KENYON JAMES (APRN)
Entity Type:Individual
Prefix:MR
First Name:KENYON
Middle Name:JAMES
Last Name:BOTT
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 N 500 W
Mailing Address - Street 2:
Mailing Address - City:HYRUM
Mailing Address - State:UT
Mailing Address - Zip Code:84319-1080
Mailing Address - Country:US
Mailing Address - Phone:435-245-3443
Mailing Address - Fax:
Practice Address - Street 1:133 N 500 W
Practice Address - Street 2:
Practice Address - City:HYRUM
Practice Address - State:UT
Practice Address - Zip Code:84319-1080
Practice Address - Country:US
Practice Address - Phone:435-245-3443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT376170-4408363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health