Provider Demographics
NPI:1528688264
Name:VANCE, MCKENNA KELLY (BS, APRN)
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:KELLY
Last Name:VANCE
Suffix:
Gender:F
Credentials:BS, APRN
Other - Prefix:
Other - First Name:MCKENNA
Other - Middle Name:KELLY
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 N MARIO CAPECCHI DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1103
Mailing Address - Country:US
Mailing Address - Phone:801-662-4100
Mailing Address - Fax:801-662-4285
Practice Address - Street 1:4401 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3195
Practice Address - Country:US
Practice Address - Phone:801-387-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9428379-3102163WN0002X
UT9428379-4405363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care