Basic Information
| Provider Information | |||||||||
| NPI: | 1356508857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEGWALU | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATHEWS | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5250 S 320 W | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841077926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012627246 | ||||||||
| FaxNumber: | 8012623696 | ||||||||
| Practice Location | |||||||||
| Address1: | 5250 S 320 W | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841077926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012627246 | ||||||||
| FaxNumber: | 8012623696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2008 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 6697216-4405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.