Provider Demographics
NPI:1548043029
Name:IMLAY, KELLY CROSS (APRN)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:CROSS
Last Name:IMLAY
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 1:1148 S 2450 W
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-7051
Mailing Address - Country:US
Mailing Address - Phone:801-745-5794
Mailing Address - Fax:
Practice Address - Street 1:1857 N 1000 W STE 1
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8969
Practice Address - Country:US
Practice Address - Phone:801-745-5794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT196456-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty