Provider Demographics
NPI:1356353601
Name:WOSNIK, KELLY (NP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WOSNIK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1533 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1005
Mailing Address - Country:US
Mailing Address - Phone:801-894-1124
Mailing Address - Fax:801-894-1150
Practice Address - Street 1:1533 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1005
Practice Address - Country:US
Practice Address - Phone:801-894-1124
Practice Address - Fax:801-894-1150
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT327710-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQ16480Medicare UPIN