Healthcare Provider Details

I. General information

NPI: 1790699189
Provider Name (Legal Business Name): KOKO TIATIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4066 E SUNBURY LN
EAGLE MOUNTAIN UT
84005-6333
US

IV. Provider business mailing address

4066 E SUNBURY LN
EAGLE MOUNTAIN UT
84005-6333
US

V. Phone/Fax

Practice location:
  • Phone: 801-361-8399
  • Fax:
Mailing address:
  • Phone: 801-361-8399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number13389615-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: