Provider Demographics
NPI:1932839727
Name:CONNOLLY, KAITLIN DIANE (APRN)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:DIANE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 E 3900 S STE 260
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1371
Mailing Address - Country:US
Mailing Address - Phone:801-265-2000
Mailing Address - Fax:
Practice Address - Street 1:1250 E 3900 S STE 260
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1371
Practice Address - Country:US
Practice Address - Phone:801-265-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10827182-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10827182-4405OtherDOPL
UT108271723102OtherDOPL