Kellie Maria Petersen

Key facts

NPI

1124742366

Entity type

Individual (NPI type 1)

Primary specialty

Community Health Worker 172V00000X

Practice address

344 E 100 S
Salt Lake City, UT 84111-1700

Phone

(801) 428-4257

NPI assigned

Sep 30, 2022

Sex

Female

Sole proprietor

Yes

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Sep 30, 2022.

{
    "created_epoch": "1664496000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1664496000000",
    "number": "1124742366",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "344 E 100 S",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841111700",
            "telephone_number": "801-428-4257"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "344 E 100 S",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841111700",
            "telephone_number": "801-428-4257"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "KELLIE",
        "middle_name": "MARIA",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2022-09-30",
        "last_updated": "2022-09-30",
        "certification_date": "2022-09-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "172V00000X",
            "taxonomy_group": "",
            "desc": "Community Health Worker",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Salt Lake City, UT

• Holly Marie Petersen
• Jason Dayne Petersen, MD
• Jessica Marie Petersen, PA-C
• Kallie Petersen, LCSW
• Karen Petersen
• Kimberly Petersen
• Lacy Petersen
• Marilyn J Petersen, P.T.
• Marta J Petersen, M.D.
• Peggy B Petersen

All providers in Salt Lake City, UT · Community Health Worker in Utah