Provider Demographics
NPI:1639467046
Name:MILLA SOMOZA, KRYSTAL (AUD)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:MILLA SOMOZA
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 E FOREMASTER DR #360
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790
Mailing Address - Country:US
Mailing Address - Phone:435-688-8866
Mailing Address - Fax:435-688-2882
Practice Address - Street 1:2255 N 1700 W SUITE 200
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041
Practice Address - Country:US
Practice Address - Phone:801-776-2180
Practice Address - Fax:801-776-2534
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10766486-4101237600000X, 231H00000X
TX80303237600000X, 231H00000X
FL237600000X
FLAY1852231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1639467046Medicaid