Provider Demographics
NPI:1326589573
Name:JOHNSON, KATHY ANN (LM MID75)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LM MID75
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 GINGER LN
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-5859
Mailing Address - Country:US
Mailing Address - Phone:208-610-3963
Mailing Address - Fax:
Practice Address - Street 1:214 GINGER LN
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-5859
Practice Address - Country:US
Practice Address - Phone:208-610-3963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMID-75176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife