Provider Demographics
NPI:1003658006
Name:BEAGLEY, KATELYNE
Entity type:Individual
Prefix:
First Name:KATELYNE
Middle Name:
Last Name:BEAGLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11100 S RIVER HEIGHTS DR APT A118
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-6243
Mailing Address - Country:US
Mailing Address - Phone:385-290-0123
Mailing Address - Fax:
Practice Address - Street 1:11100 S RIVER HEIGHTS DR APT A118
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-6243
Practice Address - Country:US
Practice Address - Phone:385-290-0123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14008648-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist