Provider Demographics
NPI:1992465637
Name:KILPACK, DALLIN RICHARD (FNP-C)
Entity type:Individual
Prefix:
First Name:DALLIN
Middle Name:RICHARD
Last Name:KILPACK
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 W 500 S
Mailing Address - Street 2:
Mailing Address - City:MANTI
Mailing Address - State:UT
Mailing Address - Zip Code:84642-5508
Mailing Address - Country:US
Mailing Address - Phone:385-296-8427
Mailing Address - Fax:
Practice Address - Street 1:537 W 500 S
Practice Address - Street 2:
Practice Address - City:MANTI
Practice Address - State:UT
Practice Address - Zip Code:84642-5508
Practice Address - Country:US
Practice Address - Phone:385-296-8427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9114166-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily