Provider Demographics
NPI:1649016163
Name:KOOS, KYLIE MARIE (RN, BSN)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:MARIE
Last Name:KOOS
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9120 W MAUNA LOA LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-2726
Mailing Address - Country:US
Mailing Address - Phone:480-258-0529
Mailing Address - Fax:
Practice Address - Street 1:9120 W MAUNA LOA LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-2726
Practice Address - Country:US
Practice Address - Phone:480-258-0529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ218205163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management