Provider Demographics
NPI:1538636121
Name:JOHNSON, KYLEE DEE (CNM)
Entity Type:Individual
Prefix:MRS
First Name:KYLEE
Middle Name:DEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2578
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2578
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-523-8978
Practice Address - Street 1:2065 E 17TH ST STE A
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8042
Practice Address - Country:US
Practice Address - Phone:208-201-8265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID59832176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife