Provider Demographics
NPI:1699965939
Name:HURLBURT, KELLI J (DO)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:J
Last Name:HURLBURT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 S CENTENNIAL PKWY STE 235
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4148
Mailing Address - Country:US
Mailing Address - Phone:801-568-4664
Mailing Address - Fax:801-568-4665
Practice Address - Street 1:10000 S CENTENNIAL PKWY STE 235
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4148
Practice Address - Country:US
Practice Address - Phone:801-568-4664
Practice Address - Fax:801-568-4665
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO152388207Q00000X
UT7061916-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000065731Medicare PIN