Provider Demographics
NPI:1720657232
Name:MADSEN, KAYLEY
Entity Type:Individual
Prefix:
First Name:KAYLEY
Middle Name:
Last Name:MADSEN
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 1:6622 S ROYAL HARVEST WAY APT 31
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6874
Mailing Address - Country:US
Mailing Address - Phone:208-863-5550
Mailing Address - Fax:
Practice Address - Street 1:1380 E MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2123
Practice Address - Country:US
Practice Address - Phone:435-251-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT10668591-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program