Provider Demographics
NPI:1720573975
Name:FIFITA, LEILANI
Entity Type:Individual
Prefix:
First Name:LEILANI
Middle Name:
Last Name:FIFITA
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 1:1157 S REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84104-3328
Mailing Address - Country:US
Mailing Address - Phone:385-528-9143
Mailing Address - Fax:
Practice Address - Street 1:1157 S REDWOOD DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-3328
Practice Address - Country:US
Practice Address - Phone:385-528-9143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTLIC201801499364SH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTLIC201801499Medicaid