Healthcare Provider Details

I. General information

NPI: 1225852221
Provider Name (Legal Business Name): AIJEAN KANG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W TOWNE RIDGE PKWY
SANDY UT
84070-5511
US

IV. Provider business mailing address

115 W TOWNE RIDGE PKWY
SANDY UT
84070-5511
US

V. Phone/Fax

Practice location:
  • Phone: 385-308-6823
  • Fax:
Mailing address:
  • Phone: 385-308-6823
  • Fax: 801-945-4720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10394085-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: