Healthcare Provider Details

I. General information

NPI: 1700934098
Provider Name (Legal Business Name): PAMELA BALLA-DIBBLEE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12473 S MINUTEMAN DR
DRAPER UT
84020-7870
US

IV. Provider business mailing address

PO BOX 25537
SALT LAKE CITY UT
84125-0537
US

V. Phone/Fax

Practice location:
  • Phone: 801-495-7950
  • Fax:
Mailing address:
  • Phone: 801-253-5970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number308035-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: