Provider Demographics
NPI:1396976072
Name:KILDEW, KENON (NP)
Entity type:Individual
Prefix:
First Name:KENON
Middle Name:
Last Name:KILDEW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 W. JEFFERSON ST.
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-369-4590
Mailing Address - Fax:208-906-2346
Practice Address - Street 1:2402 W. JEFFERSON ST.
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-369-4590
Practice Address - Fax:208-906-2346
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1237A363LF0000X
MARN284255363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
002002503OtherMEDICARE
RIKK86131Medicaid