Provider Demographics
NPI:1851021018
Name:DISTEFANO, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DISTEFANO
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 1:2165 S 1700 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-4122
Mailing Address - Country:US
Mailing Address - Phone:860-462-8204
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT111980483102163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn