Provider Demographics
NPI:1912537887
Name:QUEZADA, KATHRYN GRACE (FNP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:GRACE
Last Name:QUEZADA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:GRACE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:165 E 100 N APT E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4630
Mailing Address - Country:US
Mailing Address - Phone:801-807-8689
Mailing Address - Fax:
Practice Address - Street 1:165 E 100 N APT E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4630
Practice Address - Country:US
Practice Address - Phone:801-807-8689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9279002-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily