Provider Demographics
NPI:1821535022
Name:KIRK, HAELLY
Entity Type:Individual
Prefix:
First Name:HAELLY
Middle Name:
Last Name:KIRK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 N 450 W
Mailing Address - Street 2:APT 208
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1480
Mailing Address - Country:US
Mailing Address - Phone:385-241-6650
Mailing Address - Fax:
Practice Address - Street 1:1724 N 450 W
Practice Address - Street 2:APT 208
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1480
Practice Address - Country:US
Practice Address - Phone:385-241-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program