Provider Demographics
NPI:1336908227
Name:GARRISON, KISHA
Entity Type:Individual
Prefix:
First Name:KISHA
Middle Name:
Last Name:GARRISON
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 1:2367 N 300 W
Mailing Address - Street 2:
Mailing Address - City:SUNSET
Mailing Address - State:UT
Mailing Address - Zip Code:84015-3401
Mailing Address - Country:US
Mailing Address - Phone:385-319-2183
Mailing Address - Fax:
Practice Address - Street 1:761 W ANTELOPE DR
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1630
Practice Address - Country:US
Practice Address - Phone:801-779-2620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8464719-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist