Healthcare Provider Details

I. General information

NPI: 1417512898
Provider Name (Legal Business Name): AMANDA KHOURY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 S 1100 E STE 210
SALT LAKE CITY UT
84102-1580
US

IV. Provider business mailing address

280 S MAIN ST
BOUNTIFUL UT
84010-6236
US

V. Phone/Fax

Practice location:
  • Phone: 801-505-5277
  • Fax: 801-505-5280
Mailing address:
  • Phone: 801-505-0821
  • Fax: 801-505-0803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number12612990-0501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: