Provider Demographics
NPI:1326584640
Name:RONNAU, KYLE JOSEPH (ARNP)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JOSEPH
Last Name:RONNAU
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1672 S WOODSAGE AVENUE
Mailing Address - Street 2:SUITE #120
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-515-2273
Mailing Address - Fax:208-525-2274
Practice Address - Street 1:1672 S WOODSAGE AVENUE
Practice Address - Street 2:SUITE #120
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-515-2273
Practice Address - Fax:208-515-2274
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55936363L00000X, 363LP0808X
IDRN-41181390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID55936OtherIDAHO STATE BOARD OF NURSING