Provider Demographics
NPI:1396342713
Name:POULSEN, KATRINA (NP-C)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:POULSEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 E RIVERSIDE DR STE 301
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-8722
Mailing Address - Country:US
Mailing Address - Phone:435-216-7000
Mailing Address - Fax:435-216-7001
Practice Address - Street 1:617 EAST RRIVERSIDE DR
Practice Address - Street 2:STE 301
Practice Address - City:ST. GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790
Practice Address - Country:US
Practice Address - Phone:435-216-7000
Practice Address - Fax:435-216-7001
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV835835208VP0000X, 363LF0000X
390200000X, 390200000X
UT70226834405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily