Healthcare Provider Details

I. General information

NPI: 1124502984
Provider Name (Legal Business Name): KISSENDRAH SUE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

01 SAGEBRUSH STREET
ISLETA NM
87022
US

IV. Provider business mailing address

PO BOX 640
ISLETA NM
87022-0640
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-4866
  • Fax: 502-869-4881
Mailing address:
  • Phone: 505-869-3200
  • Fax: 505-869-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4977
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: