Healthcare Provider Details

I. General information

NPI: 1154266864
Provider Name (Legal Business Name): KHENNADYE WILSON CHRISTIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 S 1900 W
ROY UT
84067-2920
US

IV. Provider business mailing address

4881 S 1900 W
ROY UT
84067-2920
US

V. Phone/Fax

Practice location:
  • Phone: 385-426-9644
  • Fax: 801-797-2630
Mailing address:
  • Phone: 385-426-9644
  • Fax: 801-797-2630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: