Healthcare Provider Details

I. General information

NPI: 1033028725
Provider Name (Legal Business Name): KYLIE HANSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 BONNIEBRAE CIR
IDAHO FALLS ID
83404-7306
US

IV. Provider business mailing address

1455 BONNIEBRAE CIR
IDAHO FALLS ID
83404-7306
US

V. Phone/Fax

Practice location:
  • Phone: 208-201-3690
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3071251
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: