Provider Demographics
NPI:1619411790
Name:HOWARD, KAYLENE
Entity Type:Individual
Prefix:
First Name:KAYLENE
Middle Name:
Last Name:HOWARD
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:PO BOX 331
Mailing Address - Street 2:211 N MAIN
Mailing Address - City:TROY
Mailing Address - State:ID
Mailing Address - Zip Code:83871
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 SOUTH WASHINGTON
Practice Address - Street 2:SUITE 6
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843
Practice Address - Country:US
Practice Address - Phone:208-301-2155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1953225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist