Healthcare Provider Details

I. General information

NPI: 1083453187
Provider Name (Legal Business Name): AILEE MARIE JUSTO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1978 N 1575 W
LAYTON UT
84041-1159
US

IV. Provider business mailing address

1978 N 1575 W
LAYTON UT
84041-1159
US

V. Phone/Fax

Practice location:
  • Phone: 801-755-9054
  • Fax:
Mailing address:
  • Phone: 801-755-9054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number11885253-5402
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: