Provider Demographics
NPI:1215197009
Name:STILES JOHNSON, ROSE M
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:M
Last Name:STILES JOHNSON
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 1:1304 1/2 S OWYHEE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-6011
Mailing Address - Country:US
Mailing Address - Phone:208-384-0141
Mailing Address - Fax:
Practice Address - Street 1:1304 1/2 S OWYHEE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-6011
Practice Address - Country:US
Practice Address - Phone:208-384-0141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-15
Last Update Date:2008-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID40517376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807816600Medicaid