Provider Demographics
NPI:1861667602
Name:THOMAS, KELLY LAFORGE (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LAFORGE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:RAE
Other - Last Name:LAFORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:375 CHIPETA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1260
Mailing Address - Country:US
Mailing Address - Phone:801-587-3411
Mailing Address - Fax:
Practice Address - Street 1:555 FOOTHILL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-1106
Practice Address - Country:US
Practice Address - Phone:801-581-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6851254-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine