Basic Information
| Provider Information | |||||||||
| NPI: | 1639467046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLA SOMOZA | ||||||||
| FirstName: | KRYSTAL | ||||||||
| MiddleName: | |||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1490 E FOREMASTER DR #360 | ||||||||
| Address2: | |||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356888866 | ||||||||
| FaxNumber: | 4356882882 | ||||||||
| Practice Location | |||||||||
| Address1: | 2255 N 1700 W SUITE 200 | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017762180 | ||||||||
| FaxNumber: | 8017762534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2011 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 10766486-4101 | UT | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 231H00000X | 10766486-4101 | UT | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 1639467046 | 05 | UT | MEDICAID |