Basic Information
| Provider Information | |||||||||
| NPI: | 1235227307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KITTEL | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | AHRANO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3276 ALTA HILLS DR | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840932112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019448864 | ||||||||
| FaxNumber: | 8019448864 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 S 400 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841112908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015825534 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 11/02/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0006X | 181775-1205 | UT | Y | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 999000021002 | 05 | UT | MEDICAID |