Provider Demographics
NPI:1003117516
Name:JOHNSON, KIMBERLY ANN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 BLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4227
Mailing Address - Country:US
Mailing Address - Phone:970-384-7290
Mailing Address - Fax:970-384-7293
Practice Address - Street 1:1906 BLAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4227
Practice Address - Country:US
Practice Address - Phone:970-384-7290
Practice Address - Fax:970-384-7293
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008453363LF0000X
CO201184163W00000X
CO990154363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO87336855Medicaid
CO87336855Medicaid