Provider Demographics
NPI:1720881949
Name:PEACOCK, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1274 W SAGEHILL DR
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045-4104
Mailing Address - Country:US
Mailing Address - Phone:801-471-5352
Mailing Address - Fax:
Practice Address - Street 1:1274 W SAGEHILL DR
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:UT
Practice Address - Zip Code:84045-4104
Practice Address - Country:US
Practice Address - Phone:801-471-5352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12084587-3101164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse