Healthcare Provider Details

I. General information

NPI: 1790632933
Provider Name (Legal Business Name): AKINA ANDERSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 E 3RD AVE
SALT LAKE CITY UT
84103-2660
US

IV. Provider business mailing address

321 E 3RD AVE
SALT LAKE CITY UT
84103-2660
US

V. Phone/Fax

Practice location:
  • Phone: 801-645-0843
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LS0200X
TaxonomySchool Nurse Practitioner
License Number11288012-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: