Provider Demographics
NPI:1689215964
Name:NIZAM, KINDA
Entity Type:Individual
Prefix:
First Name:KINDA
Middle Name:
Last Name:NIZAM
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 1:11114 S FARNSWORTH LN
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-5399
Mailing Address - Country:US
Mailing Address - Phone:385-231-9037
Mailing Address - Fax:
Practice Address - Street 1:515 S 700 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2801
Practice Address - Country:US
Practice Address - Phone:385-231-9037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician