Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1235704479 |
---|---|
Provider Name | Kelsie Bush |
First Address | Draper, UT 84020-5400 |
Second Address | Draper, UT 84020-5400 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2021 |
Last Update Date | 20/05/2021 |