Provider Demographics
NPI:1790567840
Name:OLIVER, KELLIE KAY (FNP-C)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:KAY
Last Name:OLIVER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:KAY
Other - Last Name:RAINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:348 N BLUFF ST STE 102
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5170
Mailing Address - Country:US
Mailing Address - Phone:435-414-0722
Mailing Address - Fax:
Practice Address - Street 1:348 N BLUFF ST STE 102
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5170
Practice Address - Country:US
Practice Address - Phone:435-414-0722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6789115-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner