Healthcare Provider Details

I. General information

NPI: 1023852696
Provider Name (Legal Business Name): KRISTA SHIMIZU ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 S 400 E
OREM UT
84097-5569
US

IV. Provider business mailing address

224 S 550 W APT B9
SPRINGVILLE UT
84663-5680
US

V. Phone/Fax

Practice location:
  • Phone: 801-709-1046
  • Fax:
Mailing address:
  • Phone: 417-833-7542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number13414536-4810
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: