Provider Demographics
NPI:1235878463
Name:ONTIVEROS, GABRIELLA
Entity Type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:
Last Name:ONTIVEROS
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 1:3375 W 7800 S APT 118
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-4551
Mailing Address - Country:US
Mailing Address - Phone:385-424-5414
Mailing Address - Fax:
Practice Address - Street 1:2411 S 1070 W STE B
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-1570
Practice Address - Country:US
Practice Address - Phone:385-261-2349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-04
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant