Provider Demographics
NPI:1043640683
Name:CASTRO, IVANNIA
Entity Type:Individual
Prefix:
First Name:IVANNIA
Middle Name:
Last Name:CASTRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4586 W 4410 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-4921
Mailing Address - Country:US
Mailing Address - Phone:801-815-0817
Mailing Address - Fax:
Practice Address - Street 1:4586 W 4410 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-4921
Practice Address - Country:US
Practice Address - Phone:801-815-0817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist