Healthcare Provider Details

I. General information

NPI: 1104744556
Provider Name (Legal Business Name): SARAH ROSE JOHNSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SARAH DAINES

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 E ANDERSON ST
IDAHO FALLS ID
83401-2020
US

IV. Provider business mailing address

635 CANYON SPRINGS DR
REXBURG ID
83440-4912
US

V. Phone/Fax

Practice location:
  • Phone: 208-432-1976
  • Fax: 208-278-7956
Mailing address:
  • Phone: 208-432-1976
  • Fax: 208-278-7956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number5381316
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: