Provider Demographics
NPI:1700907557
Name:IWAMOTO, PATTI KIYOMI (MS, CCC-A)
Entity Type:Individual
Prefix:
First Name:PATTI
Middle Name:KIYOMI
Last Name:IWAMOTO
Suffix:
Gender:F
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:P.K.
Other - Middle Name:
Other - Last Name:IWAMOTO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-A
Mailing Address - Street 1:PO BOX 520223
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84152-0223
Mailing Address - Country:US
Mailing Address - Phone:866-581-9462
Mailing Address - Fax:
Practice Address - Street 1:9071 SOUTH1300 WEST
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088
Practice Address - Country:US
Practice Address - Phone:866-581-9462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1132224101231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist