Provider Demographics
NPI:1649377540
Name:KRULL, ANGELA MARIE NICHOLSON (MD)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MARIE NICHOLSON
Last Name:KRULL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:MICHOLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10011 CENTENNIAL PKWY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4156
Mailing Address - Country:US
Mailing Address - Phone:801-676-7627
Mailing Address - Fax:801-676-7630
Practice Address - Street 1:10011 CENTENNIAL PKWY
Practice Address - Street 2:SUITE 500
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4156
Practice Address - Country:US
Practice Address - Phone:801-676-7627
Practice Address - Fax:801-676-7630
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT61429451205208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1316160534OtherGROUP NPI
UT000055950Medicare PIN