Healthcare Provider Details

I. General information

NPI: 1114672425
Provider Name (Legal Business Name): ISAAC ANSASAKYI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 10/06/2023
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3809 W 6200 S
TAYLORSVILLE UT
84129-3725
US

IV. Provider business mailing address

4460 S HIGHLAND DR STE 120
SALT LAKE CITY UT
84124-3550
US

V. Phone/Fax

Practice location:
  • Phone: 801-963-4360
  • Fax:
Mailing address:
  • Phone: 888-949-4864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: