Healthcare Provider Details

I. General information

NPI: 1366657884
Provider Name (Legal Business Name): KIYOMI ANNE HACHIYA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6440 SOUTH MILLROCK DRIVE SUITE 175
SALT LAKE CITY UT
84121
US

IV. Provider business mailing address

1978 HIGHLAND PARKWAY
ST PAUL MN
55116-1351
US

V. Phone/Fax

Practice location:
  • Phone: 800-328-3075
  • Fax:
Mailing address:
  • Phone: 651-699-9814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301093549
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number26809
License Number StateMN

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: