Healthcare Provider Details

I. General information

NPI: 1700701737
Provider Name (Legal Business Name): KAITLYN BUSHMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL DR
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

7562 S 2480 W
WEST JORDAN UT
84084-3825
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone: 801-828-0935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number11415562-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: