Provider Demographics
NPI:1629798707
Name:MCMULLIN, KALISTA MAKENZIE
Entity Type:Individual
Prefix:
First Name:KALISTA
Middle Name:MAKENZIE
Last Name:MCMULLIN
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 1:1751 RED MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:UT
Mailing Address - Zip Code:84765-5201
Mailing Address - Country:US
Mailing Address - Phone:435-669-4109
Mailing Address - Fax:
Practice Address - Street 1:168 N 100 E STE 225
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-2893
Practice Address - Country:US
Practice Address - Phone:435-669-4109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12975313-4104235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist