Provider Demographics
NPI:1669090502
Name:GUTPELL, KELLY M (MBCHB, PHD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:GUTPELL
Suffix:
Gender:F
Credentials:MBCHB, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 N MARIO CAPECCHI DR STE 1A.011
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1125
Mailing Address - Country:US
Mailing Address - Phone:801-662-5704
Mailing Address - Fax:
Practice Address - Street 1:81 N MARIO CAPECCHI DR STE 1A.011
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1125
Practice Address - Country:US
Practice Address - Phone:801-662-5704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12400188-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics