Healthcare Provider Details

I. General information

NPI: 1194669671
Provider Name (Legal Business Name): ITCHEL AILEEN GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 E 12450 S STE 204
DRAPER UT
84020-8060
US

IV. Provider business mailing address

114 E 12450 S STE 204
DRAPER UT
84020-8060
US

V. Phone/Fax

Practice location:
  • Phone: 385-434-0300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number14198557-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: