Healthcare Provider Details

I. General information

NPI: 1801801691
Provider Name (Legal Business Name): KAYDON B LUSTY CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 E 3900 S SUITE B-299
SALT LAKE CITY UT
84124-1216
US

IV. Provider business mailing address

1151 E 3900 S SUITE B-299
SALT LAKE CITY UT
84124-1216
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-6811
  • Fax: 801-268-8673
Mailing address:
  • Phone: 801-268-6811
  • Fax: 801-268-8673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number195359-4402
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: