Provider Demographics
NPI:1720302680
Name:HERLEVI, KRISTINE S (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:S
Last Name:HERLEVI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 E 3900 S
Mailing Address - Street 2:STE 200
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2332
Mailing Address - Country:US
Mailing Address - Phone:801-747-2800
Mailing Address - Fax:801-747-5222
Practice Address - Street 1:2839 ST ROSE PKWY
Practice Address - Street 2:STE 100
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4806
Practice Address - Country:US
Practice Address - Phone:702-837-8988
Practice Address - Fax:702-990-5269
Is Sole Proprietor?:No
Enumeration Date:2010-03-22
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8322950-1206363A00000X
NVPA1211363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical