Healthcare Provider Details

I. General information

NPI: 1598592792
Provider Name (Legal Business Name): KYRA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2490 PASEO VERDE PKWY STE 155
HENDERSON NV
89074-7120
US

IV. Provider business mailing address

9265 W RUSSELL RD # A358
LAS VEGAS NV
89148-1359
US

V. Phone/Fax

Practice location:
  • Phone: 702-515-4009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP-4002
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: