Provider Demographics
NPI:1124338090
Name:HERGET, KELLIE MARIE
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MARIE
Last Name:HERGET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 S 1200 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4154
Mailing Address - Country:US
Mailing Address - Phone:801-792-1622
Mailing Address - Fax:
Practice Address - Street 1:7575 S 900 E
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2343
Practice Address - Country:US
Practice Address - Phone:801-208-1031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker