Healthcare Provider Details

I. General information

NPI: 1366617110
Provider Name (Legal Business Name): FAMILIES FIRST PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 W 200 N STE 2
KAYSVILLE UT
84037-4300
US

IV. Provider business mailing address

PO BOX 95868
SOUTH JORDAN UT
84095-0868
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-8644
  • Fax:
Mailing address:
  • Phone: 801-773-8644
  • Fax: 801-927-1591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number326236-1205
License Number StateUT

VIII. Authorized Official

Name: EBONIE MARIE GONZALES
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 505-850-3769