Provider Demographics
NPI:1013619857
Name:DIETRICH, KELSEY (MSN, FNP-BC)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1477 S 500 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2046
Mailing Address - Country:US
Mailing Address - Phone:810-869-6378
Mailing Address - Fax:
Practice Address - Street 1:324 E 10TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-2869
Practice Address - Country:US
Practice Address - Phone:801-408-7660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-17
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12764506-3102163W00000X
UT12764506-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse