Provider Demographics
NPI:1861044604
Name:STAHELI, KENDRA (DNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:STAHELI
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 W COUGAR BLVD STE 601
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3331
Mailing Address - Country:US
Mailing Address - Phone:801-357-7525
Mailing Address - Fax:
Practice Address - Street 1:395 W BULLDOG BLVD STE 601
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3331
Practice Address - Country:US
Practice Address - Phone:801-357-7525
Practice Address - Fax:801-357-7746
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8632096-4405363LP0808X, 363L00000X
UT8632096-8900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTPENDINGMedicaid