Provider Demographics
NPI:1730864786
Name:ELLISON, KAITLIN (APRN)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:ELLISON
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 1:1525 E 6000 S
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-7144
Mailing Address - Country:US
Mailing Address - Phone:801-337-5800
Mailing Address - Fax:
Practice Address - Street 1:1525 E 6000 S
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-7144
Practice Address - Country:US
Practice Address - Phone:801-337-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10385255-4405363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health