Provider Demographics
NPI:1760277065
Name:DOOM, KATHY MONICA
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:MONICA
Last Name:DOOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:MONICA
Other - Last Name:WSOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5121 S COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-507-7508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-09
Last Update Date:2025-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10941430-4405363LN0000X
UT10941430-3102163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care