Provider Demographics
NPI:1770464968
Name:TRUJILLO, DIETRA
Entity type:Individual
Prefix:
First Name:DIETRA
Middle Name:
Last Name:TRUJILLO
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 1:4817 S 1115 E
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5881
Mailing Address - Country:US
Mailing Address - Phone:801-916-6636
Mailing Address - Fax:
Practice Address - Street 1:2091 E MURRAY HOLLADAY RD STE 22E
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-5174
Practice Address - Country:US
Practice Address - Phone:801-916-6636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-12
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT88-1558675225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty