Provider Demographics
NPI:1891374344
Name:WILLSON, KYLIE NICOLE (AUD)
Entity Type:Individual
Prefix:DR
First Name:KYLIE
Middle Name:NICOLE
Last Name:WILLSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5119 W DAYBREAK PKWY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-4858
Mailing Address - Country:US
Mailing Address - Phone:801-417-5734
Mailing Address - Fax:
Practice Address - Street 1:5119 W DAYBREAK PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009-4858
Practice Address - Country:US
Practice Address - Phone:801-417-5734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81251231H00000X
231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist