Healthcare Provider Details

I. General information

NPI: 1851249932
Provider Name (Legal Business Name): KYLIE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2026
Last Update Date: 03/17/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1439 ZEPOL RD APT 310
SANTA FE NM
87507-7140
US

IV. Provider business mailing address

1439 ZEPOL RD APT 310
SANTA FE NM
87507-7140
US

V. Phone/Fax

Practice location:
  • Phone: 505-361-7045
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: