Provider Demographics
NPI:1992154777
Name:NIELSEN, KELLIE (APRN, FNP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:APRN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-0719
Mailing Address - Country:US
Mailing Address - Phone:435-734-2041
Mailing Address - Fax:435-723-8028
Practice Address - Street 1:600 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3006
Practice Address - Country:US
Practice Address - Phone:435-734-2041
Practice Address - Fax:435-723-8028
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5113808-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily