Provider Demographics
NPI:1992828958
Name:TERRY, KAYLEEN (APRN)
Entity Type:Individual
Prefix:MS
First Name:KAYLEEN
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5323 WOODROW ST
Mailing Address - Street 2:STE 102
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5841
Mailing Address - Country:US
Mailing Address - Phone:801-713-1010
Mailing Address - Fax:801-713-0665
Practice Address - Street 1:5323 WOODROW ST
Practice Address - Street 2:STE 102
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5841
Practice Address - Country:US
Practice Address - Phone:801-713-1010
Practice Address - Fax:801-713-0665
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT150335-4405363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057906OtherGROUP PIN
UTUT03672OtherMEDICARE SUBMITTER ID NUM
UT000057906OtherGROUP PIN
UTUT03672OtherMEDICARE SUBMITTER ID NUM