Basic Information
Provider Information | |||||||||
NPI: | 1467402628 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HORTON | ||||||||
FirstName: | MALINDA | ||||||||
MiddleName: | KAYE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 581700 | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841581700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015812121 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 50 N MEDICAL DR | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841320001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015812121 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 204822-4405 | UT | X |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LA2200X | 204822-4405 | UT | X |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LP0200X | 204822-4405 | UT | X |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | D4828 | 05 | UT |   | MEDICAID | TPRA09164 | 01 |   | MOLINA # | OTHER | 4300252 | 05 | MT |   | MEDICAID | 71435 | 01 |   | PEHP # | OTHER | 780513 | 01 |   | DMBA # | OTHER | NP786UT | 05 | AK |   | MEDICAID | 21403 | 01 |   | UNIVERSITY HEALTH PLANS # | OTHER | QM0000063446 | 01 |   | ALTIUS # | OTHER | 20482244000001 | 01 |   | REGENCE BCBS OF UTAH # | OTHER | 87559226 | 05 | NM |   | MEDICAID |