Provider Demographics
NPI:1811764079
Name:ALT, KAILYN
Entity type:Individual
Prefix:
First Name:KAILYN
Middle Name:
Last Name:ALT
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 1:15778 N RIDGEWAY LN
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9337
Mailing Address - Country:US
Mailing Address - Phone:509-828-2692
Mailing Address - Fax:
Practice Address - Street 1:22820 E APPLEWAY AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8383
Practice Address - Country:US
Practice Address - Phone:509-828-2692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide