Healthcare Provider Details

I. General information

NPI: 1417811001
Provider Name (Legal Business Name): MAKENNA GIBBONS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12846 S QUAIL LAKE DR
RIVERTON UT
84096-2689
US

IV. Provider business mailing address

12846 S QUAIL LAKE DR
RIVERTON UT
84096-2689
US

V. Phone/Fax

Practice location:
  • Phone: 801-703-7670
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: