Healthcare Provider Details

I. General information

NPI: 1073136107
Provider Name (Legal Business Name): KAYLA OZAWA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2020
Last Update Date: 06/06/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

592 GUARDSMAN WAY
SALT LAKE CITY UT
84108
US

IV. Provider business mailing address

1740 W GERTIE AVE APT 564
SALT LAKE CITY UT
84116-4783
US

V. Phone/Fax

Practice location:
  • Phone: 801-583-9713
  • Fax:
Mailing address:
  • Phone: 808-223-0727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: